Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 16, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-04-24 to assess 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 for Institutions for the Aged or Infirm, and the agency recommended the facility be placed back in compliance effective 2025-06-10.
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 16, 2025
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 2025-04-24 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 2025-06-10.
Inspection Report
Annual Inspection
Census: 63
Capacity: 70
Deficiencies: 3
Apr 24, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and Complaint Investigation related to dietary services from 2025-04-21 through 2025-04-24. The complaint investigation found no deficiencies, but the annual survey identified noncompliance with Medicare and Medicaid participation requirements.
Findings
The facility was found noncompliant with privacy and confidentiality of records, bedrail use, and resident bed maintenance requirements. Specific deficiencies included failure to protect resident privacy by posting a turning schedule in a resident's room, failure to assess risks and obtain consent for bedrail use, and failure to conduct regular maintenance inspections of bedrails per manufacturer guidelines.
Complaint Details
Complaint Investigation (CI MS#28379) related to dietary services was conducted and no deficiencies were cited related to the complaint.
Severity Breakdown
SS=D: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a resident's right to privacy of treatment information when a turning schedule was publicly posted in the resident's room. | SS=D |
| Failure to assess risks, obtain informed consent, and conduct ongoing evaluations for bedrail use for one resident, affecting 40 residents using side rails. | SS=E |
| Failure to ensure safe maintenance and monitoring of bed rails according to manufacturer guidelines, resulting in lack of required inspections and documentation. | SS=E |
Report Facts
Census: 63
Total licensed capacity: 70
Residents using side rails: 40
BIMS score: 9
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding turning schedule posted in Resident #5's room |
| Certified Nursing Coordinator | Certified Nursing Coordinator | Confirmed use of turning schedules and physician's order for Resident #5 |
| Nurse Supervisor | Nurse Supervisor | Interviewed about facility policy on posted turning schedules |
| Director of Nursing | Director of Nursing | Acknowledged signage issue and confirmed lack of consent and assessments for bed rails |
| Administrator | Administrator | Acknowledged signage issue and lack of knowledge about bed rail regulations |
| Maintenance Supervisor | Maintenance Supervisor | Inspected Resident #5's bed for safety and compatibility |
| Occupational Therapist | Occupational Therapist | Evaluated Resident #18's bed rail suitability and recommended use |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about Resident #18's use of side rails |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about Resident #18's use of side rails |
| Maintenance Director | Maintenance Director | Confirmed lack of maintenance logs and educated on bed rail maintenance importance |
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 24, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation (CI) MS #28379 related to dietary services at the facility from 2025-04-21 through 2025-04-24. The complaint investigation found no citations regarding the complaint.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, specifically related to residents' rights. The facility failed to ensure a resident's right to privacy of treatment information when a turning schedule was publicly posted in Resident #5's room, visible to anyone entering the room.
Complaint Details
The complaint investigation MS #28379 related to dietary services was conducted and found no citations regarding the complaint.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident's right to privacy of treatment information when a turning schedule was publicly posted in Resident #5's room. | Level II |
Report Facts
Number of sampled residents: 16
BIMS score: 9
Dates of survey: 4
Rooms monitored per week: 4
Monitoring duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding the turning schedule posted in Resident #5's room. |
| Certified Nursing Coordinator | Certified Nursing Coordinator | Confirmed use of turning schedules as visual reminders and lack of family permission for signage. |
| Nurse Supervisor | Nurse Supervisor | Interviewed about lack of formal policy on posted turning schedules and no family permission for signage. |
| Director of Nursing | Director of Nursing | Acknowledged signage in Resident #5's room and planned removal and staff education. |
| Administrator | Administrator | Acknowledged awareness of posted signage and immediate plan for removal and staff education. |
Inspection Report
Annual Inspection
Census: 63
Capacity: 70
Deficiencies: 3
Apr 24, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and Complaint Investigation related to dietary services from 2025-04-21 through 2025-04-24.
Findings
No deficiencies were cited 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 cited for deficiencies F583, F700, and F909.
Complaint Details
Complaint Investigation MS#28379 related to dietary services was investigated and no deficiencies were cited related to the complaint.
Deficiencies (3)
| Description |
|---|
| Deficiency cited as F583 |
| Deficiency cited as F700 |
| Deficiency cited as F909 |
Report Facts
Census: 63
Total licensed capacity: 70
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 24, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation related to dietary services at the facility from 2025-04-21 through 2025-04-24.
Findings
No citations were issued regarding the complaint investigation. However, the facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and was cited M500.
Complaint Details
Complaint Investigation MS #28379 related to dietary services was conducted and no citations were issued regarding the complaint.
Deficiencies (1)
| Description |
|---|
| Facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and cited M500. |
Inspection Report
Life Safety
Deficiencies: 0
Apr 22, 2025
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 Life Safety Code deficiencies cited during the survey.
Inspection Report
Life Safety
Deficiencies: 0
Apr 22, 2025
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 with no deficiencies cited during this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 27, 2025
Visit Reason
The State Agency conducted a complaint survey at the facility for one complaint (MS#27883) on 02/27/2025.
Findings
The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. The investigation covered infection control, responsible party notification, pressure sores, and quality of life, with no deficiencies cited.
Complaint Details
The complaint investigation for MS#27883 was not substantiated as no deficiencies were cited related to infection control, responsible party notification, pressure sores, or quality of life.
Report Facts
Number of complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 64
Capacity: 65
Deficiencies: 0
Feb 27, 2025
Visit Reason
The State Agency conducted a complaint investigation related to pharmaceutical services, neglect, and misappropriation of property.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint Investigation (CI), MS #27883, related to pharmaceutical services, neglect, and misappropriation of property. No deficiencies were cited.
Report Facts
Licensed beds: 65
Census: 64
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 9, 2025
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2025-01-02 to determine 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 2025-02-07.
Complaint Details
The visit was related to a complaint survey completed on 2025-01-02. The facility was found in compliance and the complaint was effectively resolved.
Report Facts
Complaint survey date: Jan 2, 2025
Desk review date: Feb 9, 2025
Compliance effective date: Feb 7, 2025
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 9, 2025
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2025-01-02 to verify corrective measures taken by the facility.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 2025-02-07.
Complaint Details
The visit was complaint-related, reviewing corrective actions following a complaint survey completed on 2025-01-02. The facility's corrective measures were confirmed and compliance was recommended.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 2, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27071, at the facility related to abuse and resident rights.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, specifically failing to ensure a resident's right to be treated with respect and dignity when a Certified Nurse Aide refused to provide requested assistance.
Complaint Details
The complaint involved an incident on 11/11/2024 where CNA #2 refused to assist Resident #1 with changing clothes and getting into bed, stating she was only there to assist with toileting. The allegation was supported by a preponderance of evidence. Resident #1 denied psychological distress. CNA #2 resigned on 11/15/2024. The facility implemented staff in-service and monitoring to ensure resident dignity and respect.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident's right to be treated with respect and dignity when a Certified Nurse Aide refused to provide assistance requested by the resident. | Level II |
Report Facts
Number of sampled residents: 5
Date of incident: Nov 11, 2024
Date of complaint received: Nov 14, 2024
Date of CNA resignation: Nov 15, 2024
BIMS score: 15
Resident admission date: Aug 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in refusal to assist Resident #1 and subsequent resignation |
| CNA Supervisor #1 | CNA Supervisor | Provided interview about CNA #2's work performance and conduct |
| Licensed Social Worker | Licensed Social Worker | Conducted resident interviews and monitoring related to complaint |
| Nursing Home Administrator | Nursing Home Administrator | Explained investigation findings and actions taken |
| Director of Nursing | Director of Nursing | Involved in investigation and staff education |
| Staff Educator | Registered Nurse | Conducted in-service training on resident rights |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 70
Deficiencies: 1
Jan 2, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27071, related to resident abuse and resident rights at the facility on 01/02/2025.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to failure to ensure a resident's right to be treated with respect and dignity. Specifically, a Certified Nurse Aide (CNA) refused to assist Resident #1 with requested care tasks, violating resident rights.
Complaint Details
The complaint investigation was triggered by a facility reported investigation related to resident abuse and resident rights. The allegation that CNA #2 refused to assist Resident #1 with care tasks was supported by a preponderance of evidence. Resident #1 described the CNA's behavior as dismissive and unprofessional. CNA #2 resigned prior to completion of the investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident's right to be treated with respect and dignity when a CNA refused to provide assistance requested by Resident #1. | SS=D |
Report Facts
Licensed beds: 70
Resident census: 63
Plan of correction completion date: Feb 7, 2025
Resident assistance order date: Nov 7, 2024
Complaint incident date: Nov 11, 2024
Complaint report date: Nov 14, 2024
CNA resignation date: Nov 15, 2024
Resident admission date: Aug 23, 2024
MDS Assessment Reference Date: Nov 21, 2024
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in finding for refusing to assist Resident #1 and exhibiting dismissive behavior |
| CNA Supervisor #1 | CNA Supervisor | Interviewed regarding CNA #2's conduct and employment status |
| Nursing Home Administrator | Administrator | Provided information on investigation and CNA #2's removal and resignation |
| Staff Educator, RN | Staff Educator, Registered Nurse | Conducted in-service training on resident rights for nursing staff |
| Licensed Social Worker | Licensed Social Worker | Interviewed Resident #1 post-incident and implemented monitoring of resident respect |
| Director of Nursing | Director of Nursing | Involved in statement collection and planned audits for compliance |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 13, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-10 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; no deficiencies were noted in this plan of correction document.
Inspection Report
Annual Inspection
Census: 60
Capacity: 65
Deficiencies: 0
Jan 10, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 1/8/24 through 1/10/24 to determine compliance with Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements at the time of the survey.
Inspection Report
Annual Inspection
Census: 60
Capacity: 65
Deficiencies: 1
Jan 10, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from January 8, 2024 through January 10, 2024 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance due to failure to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident with new mental health diagnoses. Specifically, Resident #29 had new diagnoses added after admission, but the facility did not submit the required PASARR Level II change in status request.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident with new mental health diagnoses. | SS=D |
Report Facts
Licensed beds: 65
Census: 60
Residents requiring PASRR Level II Change in Status Request: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Interviewed regarding PASARR process and failure to submit Level II change in status request | |
| Social Worker #2 | Confirmed failure to submit Level II change in status request for Resident #29 | |
| Psychiatric Nurse Practitioner | Responsible for completing PASARR Level II Change in Status Requests | |
| Nursing Home Administrator | In-serviced clinicians, social workers, and Director of Nursing on PASARR process | |
| Minimum Data Set Department Coordinator | Completed resident diagnosis history review identifying residents needing PASARR Level II requests | |
| Quality Assurance Nurse | Monitors physician orders and PASARR submissions, reports findings to Quality Assurance Committee |
Inspection Report
Life Safety
Deficiencies: 0
Jan 10, 2024
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
Jan 10, 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
Jan 10, 2024
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 01/10/24 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility had implemented measures to correct the deficient practices identified in the annual survey and was found to be back in compliance effective 02/09/24.
Inspection Report
Follow-Up
Census: 50
Capacity: 60
Deficiencies: 0
Feb 2, 2022
Visit Reason
The State Agency conducted a follow-up/revisit survey on 02/02/2022 for an Annual Survey originally conducted from 11/16/2021 through 11/19/2021.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements effective 12/29/2021.
Inspection Report
Follow-Up
Census: 50
Capacity: 60
Deficiencies: 0
Feb 2, 2022
Visit Reason
The State Agency conducted a follow-up/revisit survey on 2/2/22 for an Annual Survey originally conducted from 11/16/21 through 11/19/21.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid effective 12/29/2021.
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 13, 2021
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 between 12/06/2021 and 12/12/2021 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Life Safety
Deficiencies: 0
Nov 22, 2021
Visit Reason
The facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider to assess compliance with the 2012 Edition of the Life Safety Code (LSC).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Nov 22, 2021
Visit Reason
The survey was conducted to assess the facility's compliance with applicable Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements as of the survey date.
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 1
Nov 19, 2021
Visit Reason
The State Agency conducted an annual recertification survey from 11/16/2021 to 11/19/2021 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 a deficiency related to urinary incontinence care, specifically failure to prevent possible spread of infection during incontinent care for one resident. Deficient practices involved improper hand hygiene and infection control by Certified Nursing Assistants during peri-care.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent possible spread of infection during incontinent care for Resident #28, including improper hand hygiene and not using barriers as per facility policy. | Level II |
Report Facts
Licensed beds: 60
Resident census: 54
Deficiency count: 1
Monitoring percentage: 10
Monitoring duration: 4
Monitoring duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in deficient infection control practice during peri-care for Resident #28 |
| Certified Nursing Assistant #2 | CNA | Named in deficient infection control practice during peri-care for Resident #28 |
| Director of Nursing | RN | Provided assessment and training related to deficient infection control practices |
| Registered Nurse #2 | Infection Control Nurse | Interviewed regarding infection risk and CNA skill check-offs |
| Registered Nurse #3 | MDS/Care Plan Nurse | Interviewed regarding potential resident risks from deficient care |
| Registered Nurse #1 | Professional Development Nurse/Nurse Educator | Interviewed regarding CNA knowledge and infection control |
| Nurse Educator | RN | Conducted in-service training and monitoring implementation |
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 2
Nov 19, 2021
Visit Reason
The State Agency conducted an annual survey at the facility from 11/16/21 through 11/19/21 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 failure to develop and implement a comprehensive care plan and failure to prevent possible spread of infection during incontinent care for Resident #28.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow the care plan for Resident #28 during peri-care, including improper handling of wipes and gloves, risking infection. | SS=D |
| Failure to prevent possible spread of infection during incontinent care for Resident #28, including improper hand hygiene and lack of barrier use. | SS=D |
Report Facts
Licensed beds: 60
Resident census: 54
Deficiencies cited: 2
Care plan problem onset date: Jan 13, 2021
Assessment Reference Date: Sep 20, 2021
Physician order date: Jun 25, 2021
Training completion date: Dec 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in deficiency for not following care plan and infection control policies for Resident #28 |
| Certified Nursing Assistant #2 | CNA | Named in deficiency for not following care plan and infection control policies for Resident #28 |
| Director of Nursing | RN | Provided training and conferences to CNAs regarding deficient practices |
| Registered Nurse #2 | Infection Control Nurse | Interviewed regarding infection risks and CNA skill check-offs |
| Registered Nurse #3 | MDS/Care Plan Nurse | Interviewed regarding importance of following care plan |
| Registered Nurse #1 | Professional Development Nurse/Nurse Educator | Interviewed regarding CNA knowledge and training |
Inspection Report
Abbreviated Survey
Census: 66
Capacity: 106
Deficiencies: 0
Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency from January 12 to January 13, 2021, including complaint investigations CI #16874 and CI #16844.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented recommended practices by CMS and CDC to prepare for COVID-19. The State Agency did not substantiate the complaints for Quality of Care/Abuse and no deficiencies were cited.
Complaint Details
The State Agency did not substantiate complaint investigations CI #16874 and CI #16844 for Quality of Care/Abuse.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on January 12 and 13, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Abbreviated Survey
Census: 66
Capacity: 106
Deficiencies: 0
Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted along with complaint investigations CI #16874 and CI #16844 to assess infection control compliance and quality of care/abuse allegations.
Findings
The facility was found to be in compliance with infection control regulations and had implemented recommended COVID-19 practices. The State Agency did not substantiate the complaints for Quality of Care/Abuse and no deficiencies were cited.
Complaint Details
The complaints CI #16874 and CI #16844 related to Quality of Care/Abuse were not substantiated by the State Agency.
Report Facts
Census: 66
Total licensed capacity: 106
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/12/21 and 1/13/21 to assess compliance with relevant federal regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness for COVID-19.
Inspection Report
Routine
Census: 95
Capacity: 106
Deficiencies: 0
May 20, 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.
Inspection Report
Routine
Census: 95
Capacity: 106
Deficiencies: 0
May 20, 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.
Inspection Report
Abbreviated Survey
Census: 95
Capacity: 106
Deficiencies: 0
May 20, 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.
Inspection Report
Complaint Investigation
Census: 97
Capacity: 120
Deficiencies: 3
Nov 21, 2019
Visit Reason
Complaint investigation initiated due to an Immediate Jeopardy related to neglect/supervision after a resident choked on the wrong diet served.
Findings
The facility failed to serve Resident #1 the correct Mechanical Soft Diet with Chopped Meats on 10/24/19, instead serving a Regular Diet with whole sliced turkey, resulting in choking, cardiopulmonary arrest, hospitalization, ventilator placement, and death on 10/27/19. Staff also attempted to cover up the error by switching meal tickets. The facility implemented corrective actions and training, and the Immediate Jeopardy was removed prior to the survey.
Complaint Details
Complaint investigation substantiated for neglect/supervision related to Resident #1 choking on the wrong diet served. Immediate Jeopardy identified and removed after corrective actions.
Severity Breakdown
Level IV: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 was served the correct diet consistency, resulting in choking and death. | Level IV |
| Failure to provide adequate supervision during meal service to prevent accidents and hazards, resulting in Resident #1 choking and death. | Level IV |
| Failure to serve therapeutic diet in accordance with physician's order, resulting in Resident #1 choking and death. | Level IV |
Report Facts
Facility census: 97
Facility total capacity: 120
Residents with mechanically altered diets: 39
Staff suspended/terminated: 4
Date of choking incident: Oct 24, 2019
Date of Resident #1 death: Oct 27, 2019
Date Immediate Jeopardy removed: Oct 26, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Failed to supervise meal service and verify correct diet; resigned after incident |
| CNA #1 | Certified Nursing Assistant | Served wrong diet tray to Resident #1; terminated after incident |
| CNA #2 | Certified Nursing Assistant | Involved in diet error and cover-up; terminated after incident |
| CNA #3 | Certified Nursing Assistant | Involved in diet error and cover-up; terminated after incident |
| LPN #1 | Licensed Practical Nurse / Facility Investigator | Conducted investigation confirming staff negligence |
| RN #2 | Registered Nurse / Educator | Confirmed staff training on diet and meal service policies |
| Speech Therapist #1 | Speech Therapist | Recommended Mechanical Soft Diet with Chopped Meats for Resident #1 |
| Dietary Manager | Responsible for dietary department and meal preparation | |
| Registered Dietician | Provided training on therapeutic diets and meal service | |
| QA Nurse / RN #4 | Quality Assurance Nurse | Participated in QA meeting and validated corrective actions |
| Administrator | Notified of Immediate Jeopardy and participated in investigation | |
| Director of Nursing (DON) | Confirmed staff misconduct and training |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 120
Deficiencies: 4
Nov 21, 2019
Visit Reason
Complaint investigation initiated due to an Immediate Jeopardy related to neglect/supervision after a resident choked on the wrong diet served by the facility.
Findings
The facility failed to provide Resident #1 with the correct Mechanical Soft Diet with Chopped Meats, instead serving a Regular Diet with whole sliced turkey, resulting in choking, cardiopulmonary arrest, hospitalization, and death. Staff dishonestly switched meal tickets to cover the error. The facility failed to follow the resident's care plan and provide adequate supervision during meal service. Immediate Jeopardy was removed after corrective actions and staff training were implemented.
Complaint Details
Complaint investigation substantiated for neglect/supervision after Resident #1 choked on the wrong diet served by the facility on 10/24/19, resulting in death on 10/27/19.
Severity Breakdown
Immediate Jeopardy: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 was free from neglect by serving the wrong diet consistency, resulting in choking and death. | Immediate Jeopardy |
| Failure to develop and implement a comprehensive care plan consistent with resident needs, resulting in Resident #1 receiving the wrong diet. | Immediate Jeopardy |
| Failure to provide adequate supervision and assistance during meal service to prevent accidents, resulting in Resident #1 choking and death. | Immediate Jeopardy |
| Failure to serve food in a form designed to meet individual needs, resulting in Resident #1 receiving the wrong diet and subsequent death. | Immediate Jeopardy |
Report Facts
Facility census: 97
Facility total capacity: 120
Residents with mechanically altered diets: 39
Staff involved in incident: 4
Date of choking incident: Oct 24, 2019
Date of death: Oct 27, 2019
Date of survey: Nov 21, 2019
Date of Immediate Jeopardy removal: Oct 26, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Assigned to dining room, failed to supervise meal service and verify correct diet; resigned after incident |
| CNA #1 | Certified Nursing Assistant | Served Resident #1 wrong diet tray; terminated after incident |
| CNA #2 | Certified Nursing Assistant | Placed Resident #1's meal tray unattended, which was eaten by Resident #2; terminated after incident |
| CNA #3 | Certified Nursing Assistant | Switched meal tickets to cover error; terminated after incident |
| LPN #1 | Licensed Practical Nurse / Facility Investigator | Conducted investigation confirming staff negligence in serving wrong diet |
| RN #2 | Registered Nurse / Educator | Confirmed staff training on food service duties and abuse/neglect policies |
| RD | Registered Dietician | Confirmed care plan and staff training on therapeutic diets |
| ST #1 | Speech Therapist | Recommended Mechanical Soft Diet with Chopped Meats for Resident #1 |
| ST #2 | Speech Therapist | Photographed Resident #1's meal tray showing wrong diet served |
| DON | Director of Nursing | Confirmed staff dishonesty and failure to follow protocols |
| Administrator | Confirmed video evidence of choking incident and staff misconduct |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 24, 2019
Visit Reason
The State Agency conducted a complaint investigation on April 24, 2019, to investigate allegations of abuse, neglect, or accidents.
Findings
The investigation was unable to substantiate abuse, neglect, or accidents related to the complaint.
Complaint Details
The complaint investigation was conducted by the State Agency and was unable to substantiate abuse, neglect, or accidents.
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 17, 2019
Visit Reason
The State Agency conducted an annual recertification survey along with a complaint investigation from 04/14/19 to 04/17/19 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance due to improper storage of drugs and biologicals, specifically expired medication found in one of two medication rooms. The complaint investigation was not substantiated for abuse and no citations were related to the complaint.
Complaint Details
Complaint investigation MS #15609 was not substantiated for abuse and no citations were related to the complaint.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Expired medication (Liquid Tylenol Pain and Fever) found in the medication room on Magnolia Hall. | SS=D |
Report Facts
Number of medication rooms observed: 2
Number of expired medication bottles found: 3
Completion date for plan of correction: May 17, 2019
Dates of survey: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed and stated she did not know the facility's policy for checking expired medications. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed and stated the Medication Nurse was responsible for checking expired medications. | |
| Nursing Supervisor | Interviewed and stated the Medication Nurse was responsible for checking expired medications and notifying the RN Supervisor. |
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 17, 2019
Visit Reason
The State Agency conducted an Annual State Licensure survey, along with an Annual Recertification survey, and a Complaint Investigation from 04/14/2019 to 04/17/2019.
Findings
The facility was found not in compliance with State Licensure requirements due to failure to properly store drugs and biologicals, specifically expired medication found in one of two medication rooms. The complaint investigation was not substantiated and no citations were related to the complaint.
Complaint Details
Complaint Investigation (CI MS #15609) was not substantiated for abuse, and no citations were related to the complaint.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly store drugs and biologicals as evidenced by expired medication in the medication room on Magnolia Hall. | Level II |
Report Facts
Expired medication count: 3
Medication rooms observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed and stated she did not know the facility's policy for checking expired medications. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed and stated the Medication Nurse was responsible for checking expired medications. | |
| Nursing Supervisor | Interviewed and stated the Medication Nurse was responsible for checking expired medications and notifying the RN Supervisor for removal and disposal. | |
| Quality Assurance Nurse | Checked 100% of floor stock medication in all medication rooms on April 17, 2019. | |
| Pharmacy Consultant | Will check 100% of floor stock medication expiration dates monthly beginning May 2, 2019. | |
| Director of Nursing and/or Nursing Supervisor | Will report any deficiencies to the Quality Assurance Committee. |
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 17, 2019
Visit Reason
The State Agency conducted an Annual State Licensure survey, along with an Annual Recertification survey, and a Complaint Investigation from 04/14/2019 to 04/17/2019.
Findings
The facility was found not in compliance with State Licensure requirements due to failure to properly store drugs and biologicals, specifically expired medication found in one of two medication rooms. The complaint investigation was not substantiated and no citations were related to the complaint.
Complaint Details
Complaint Investigation (CI MS #15609) was conducted but was not substantiated for abuse and no citations were related to the complaint.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly store drugs and biologicals as evidenced by expired medication in the medication room on Magnolia Hall. | Level II |
Report Facts
Expired medication count: 3
Medication rooms observed: 2
In-service completion date: Apr 24, 2019
Quality Assurance checks: 50
Quality Assurance checks: 25
Pharmacy Consultant checks: 100
Pharmacy Consultant checks: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed and stated she did not know the facility's policy for checking expired medications. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed and stated the Medication Nurse was responsible for checking expired medications. | |
| Nursing Supervisor | Interviewed and stated the Medication Nurse was responsible for checking expired medications and notifying the RN Supervisor. | |
| James T. Champion Quality Assurance Nurse | Quality Assurance Nurse | Checked 100% of floor stock medication on April 17, 2019 and will monitor medication expiration checks monthly. |
| James T. Champion Pharmacy Consultant | Pharmacy Consultant | Will check 100% of floor stock medication monthly for three months and then 50% monthly thereafter. |
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