Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 90
Capacity: 105
Deficiencies: 0
Nov 17, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 11/17/2025 related to the complaint survey conducted on 9/02/2025 through 9/03/2025.
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 10/07/2025.
Complaint Details
The visit was related to a complaint survey conducted on 9/02/2025 through 9/03/2025. The follow-up found the facility in compliance.
Report Facts
Licensed beds: 105
Resident census: 90
Inspection Report
Follow-Up
Deficiencies: 0
Nov 17, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 11/17/2025 related to a complaint survey conducted from 9/2/2025 through 9/3/2025.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back into compliance effective 10/7/2025.
Complaint Details
The revisit was related to a complaint survey conducted from 9/2/2025 through 9/3/2025. The facility was found to be in compliance upon follow-up.
Inspection Report
Complaint Investigation
Census: 90
Capacity: 105
Deficiencies: 0
Nov 17, 2025
Visit Reason
The State Agency conducted a Complaint Investigation related to Quality of Care, Neglect, and Resident Rights at the facility on 11/17/2025.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements with no deficiencies cited. However, the facility remains out of compliance due to deficiencies cited in a prior survey on 09/03/2025.
Complaint Details
Complaint Investigation (CI MS #2656720) related to Quality of Care, Neglect, and Resident Rights was conducted and found no deficiencies during this visit.
Report Facts
Licensed beds: 105
Census: 90
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 17, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2656720, related to Quality of Care, Neglect, and Resident Rights at the facility.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited. However, the facility remains out of compliance due to deficiencies cited on the 09/03/25 survey.
Complaint Details
Complaint Investigation MS #2656720 was related to Quality of Care, Neglect, and Resident Rights and was not substantiated as no deficiencies were cited during this investigation.
Report Facts
Complaint Investigation Number: 2656720
Inspection Report
Complaint Investigation
Census: 90
Capacity: 105
Deficiencies: 1
Sep 3, 2025
Visit Reason
The State Agency conducted complaint investigations related to nursing services, quality of care/treatment, physical environment, physician services, neglect, and resident rights/discharge rights at the facility.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements related to resident discharge rights, specifically failing to provide all medications, including as-needed pain medications, to one discharged resident. No deficiencies were cited for other complaint investigations.
Complaint Details
Complaint investigations CI MS #475480, CI MS# 2568468, and CI MS# 2583490 were conducted. CI MS #2568468 was substantiated with a deficiency cited related to resident discharge rights and medication provision. The other complaint investigations found no deficiencies.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure resident discharge rights by not providing all medications, specifically as needed pain medications, for one of four discharged residents (Resident #1). | SS = D |
Report Facts
Census: 90
Total licensed capacity: 105
Quantity of Hydrocodone-Acetaminophen tablets destroyed: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication provision at discharge for Resident #1. |
| Director of Nursing | Director of Nursing | Interviewed and confirmed medication discharge policies and specific medication orders for Resident #1. |
| Administrator | Administrator | Interviewed regarding facility policy on medication discharge with residents. |
| Minimum Data Set Nurse | MDS Nurse | Participated in discharge planning and interviewed about Resident #1's discharge process. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 3, 2025
Visit Reason
The State Agency conducted complaint investigations related to nursing services, quality of care/treatment, physical environment, physician services, neglect, and resident rights/discharge rights at Lakeland Nursing and Rehabilitation Center LLC.
Findings
The facility was found not in compliance with state licensure requirements related to resident discharge rights by failing to provide all medications, specifically as needed pain medications, for one of four discharged residents. No deficiencies were cited for other complaint investigations.
Complaint Details
Complaint Investigations CI MS #475480 and CI MS #2583490 related to nursing services, quality of care, call light function, and physical environment had no deficiencies cited. CI MS #2568468 related to physician services, neglect, and resident rights/discharge rights was substantiated with a deficiency cited.
Deficiencies (1)
| Description |
|---|
| Failed to ensure resident discharge rights by not providing all medications, specifically as needed pain medications, for one discharged resident. |
Report Facts
Medication quantity destroyed: 29
Assessment Reference Date: Jun 20, 2025
Admission date: Jun 13, 2025
Discharge date: Jun 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed not sending Hydrocodone-Acetaminophen tablets home with Resident #1 at discharge |
| Medical Doctor #1 | Primary Healthcare Physician | Signed History and Physical for Resident #1 |
| Director of Nursing | Director of Nursing | Confirmed medication orders and discharge procedures for Resident #1 |
| Administrator | Facility Administrator | Confirmed facility policy on medication discharge procedures |
| Minimum Data Set Nurse | MDS Nurse | Participated in discharge planning for Resident #1 |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 105
Deficiencies: 0
May 20, 2025
Visit Reason
The State Agency conducted a complaint investigation related to admission/transfer/discharge rights, quality of care regarding resident safety/falls, accidents related to unwitnessed falls, and neglect.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation (CI MS #28827) was substantiated with no deficiencies cited.
Report Facts
Licensed beds: 105
Census: 90
Inspection Report
Complaint Investigation
Deficiencies: 0
May 20, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #28827, related to admission/transfer/discharge rights, quality of care regarding resident safety/falls, accidents related to unwitnessed falls and neglect.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #28827 was related to admission/transfer/discharge rights, quality of care regarding resident safety/falls, accidents related to unwitnessed falls and neglect. The complaint was not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 93
Capacity: 105
Deficiencies: 0
Apr 8, 2025
Visit Reason
The State Agency conducted three complaint investigations at the facility from 2025-04-07 through 2025-04-08. The investigations were related to abuse and neglect, and staffing concerns on the 3-11 and 11-7 shifts.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements with no deficiencies cited during the complaint investigations.
Complaint Details
Three complaint investigations were conducted: CI MS #28309 regarding abuse and neglect, and CI MS #28361 and CI MS #28322 regarding staffing on the 3-11 and 11-7 shifts. No deficiencies were cited.
Report Facts
Beds licensed: 105
Census: 93
Inspection Report
Complaint Investigation
Census: 93
Capacity: 105
Deficiencies: 0
Apr 8, 2025
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 4/7/25 through 4/8/25 regarding abuse and neglect and staffing concerns on the 3-11 and 11-7 shifts.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements with no deficiencies cited.
Complaint Details
Complaint Investigation MS #28361, MS #28322, and MS #28309 were conducted. MS #28309 was investigated for abuse and neglect. MS #28361 and MS #28322 were investigated for staffing on the 3-11 and 11-7 shifts. No deficiencies were cited.
Report Facts
Licensed beds: 105
Census: 93
Inspection Report
Follow-Up
Census: 82
Capacity: 105
Deficiencies: 0
Mar 11, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 3/11/25 related to the annual recertification and complaint survey conducted from 1/27/25 through 1/30/25.
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 3/10/25.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 11, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 3/11/25 related to the annual recertification and complaint survey conducted from 1/27/25 through 1/30/25.
Findings
The State Agency found the facility to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, recommending the facility be placed back in compliance effective 3/10/25.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 24, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27947, regarding bowel and bladder, grooming, not following physician orders, quality of care, and resident rights.
Findings
No deficiencies were cited related to the complaint survey; however, the facility remains out of compliance with state licensure requirements due to deficiencies cited on the 01/30/25 survey.
Complaint Details
Complaint Investigation MS #27947 was investigated regarding bowel and bladder, grooming, not following physician orders, quality of care, and resident rights. No deficiencies were cited related to the complaint survey.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 105
Deficiencies: 0
Feb 24, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27947, regarding bowel and bladder, grooming, not following physician orders, quality of care, and resident rights.
Findings
No deficiencies were cited related to the complaint survey; however, the facility remains out of compliance due to deficiencies cited during the 01/30/25 survey.
Complaint Details
Complaint Investigation MS #27947 was investigated regarding bowel and bladder, grooming, not following physician orders, quality of care, and resident rights. No deficiencies were cited related to the complaint survey.
Report Facts
Licensed beds: 105
Census: 89
Inspection Report
Annual Inspection
Census: 87
Capacity: 105
Deficiencies: 8
Jan 30, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 1/27/25 through 1/30/25 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with multiple requirements including safe environment, accuracy of assessments, comprehensive care plans, sufficient nursing staff, medication security, food safety, resident records, and infection prevention and control. Specific deficiencies included torn flooring posing fall risk, inaccurate MDS coding, incomplete care plans, insufficient staffing on several days, medications left unattended, improper food thermometer sanitation, incomplete advance directive documentation, and failure to follow enhanced barrier precautions.
Complaint Details
Complaint investigations included CI MS #27735 for medication administration and quality of care with no citations; CI MS #27678 for staffing, grooming, weight loss, bowel and bladder, and falls with citation F725; and CI MS #27680 for sufficient staffing levels with citation F725.
Severity Breakdown
SS=E: 4
SS=D: 3
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents' right to a homelike environment due to torn and buckling flooring in Resident #5's room. | SS=E |
| Failed to accurately code a Minimum Data Set (MDS) assessment for Resident #83 discharged home but coded as discharged to hospital. | SS=D |
| Failed to develop a person-centered care plan regarding impaired vision for Resident #68. | SS=D |
| Failed to ensure sufficient nursing staff to meet residents' needs on four days in January 2025. | SS=F |
| Failed to ensure medications were secured and inaccessible to unauthorized residents and staff; medications left unattended at bedside for Residents #5 and #56. | SS=D |
| Failed to ensure proper food handling and sanitation; dietary staff failed to sanitize thermometer properly when checking food temperatures. | SS=E |
| Failed to maintain complete and accurate medical records by not documenting residents' informed rights regarding Advance Directives for Residents #22, #27, and #61. | SS=D |
| Failed to ensure Enhanced Barrier Precautions were followed; nurses did not wear gowns when providing care to Resident #27 requiring high-contact precautions. | SS=E |
Report Facts
Census: 87
Total Capacity: 105
Staffing Deficient Days: 4
Deficiency Count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Left medication unattended at Resident #5's bedside |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Acknowledged medication cream left at Resident #56's bedside |
| Licensed Practical Nurse #2 | Nursing Supervisor | Observed administering medications without gown to Resident #27 and acknowledged failure |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Observed performing PEG tube care without gown for Resident #27 |
| Social Services Director | Social Services Director | Responsible for Advance Directive documentation; acknowledged incomplete records |
| Dietary Cook #2 | Dietary Cook | Failed to sanitize thermometer properly when checking food temperatures |
| Administrator | Administrator | Confirmed medication left unattended and incomplete Advance Directive documentation |
Inspection Report
Annual Inspection
Census: 87
Capacity: 105
Deficiencies: 8
Jan 30, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 1/27/25 through 1/30/25 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with multiple requirements including safe environment, accuracy of assessments, comprehensive care planning, sufficient nursing staff, medication security, food safety, resident records, and infection prevention and control. Specific deficiencies were cited related to flooring hazards, inaccurate MDS coding, incomplete care plans, staffing shortages, unsecured medications, improper food thermometer sanitation, incomplete advance directive documentation, and failure to follow enhanced barrier precautions.
Complaint Details
Complaint investigations included CI MS #27735 (medications administration and quality of care, no citations), CI MS #27678 (staffing, grooming, weight loss, bowel and bladder, falls; citation F725), and CI MS #27680 (sufficient staffing levels; citation F725).
Severity Breakdown
SS=E: 4
SS=D: 3
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents' right to a homelike environment due to torn flooring posing a fall risk for Resident #5. | SS=E |
| Failed to accurately code a Minimum Data Set (MDS) assessment for Resident #83 discharged home but coded as discharged to hospital. | SS=D |
| Failed to develop a person-centered care plan regarding impaired vision for Resident #68. | SS=D |
| Failed to ensure sufficient nursing staff to meet resident needs on multiple days in January 2025. | SS=F |
| Failed to ensure medications were secured and inaccessible to unauthorized residents and staff; medications left unattended at bedside for Residents #5 and #56. | SS=D |
| Failed to ensure proper food handling and sanitation practices; thermometer not sanitized properly during tray line temperature checks. | SS=E |
| Failed to maintain complete and accurate medical records by not documenting residents' informed rights regarding Advance Directives for Residents #22, #27, and #61. | SS=D |
| Failed to ensure Enhanced Barrier Precautions were followed; nurses did not wear gowns when providing care to Resident #27 requiring high-contact precautions. | SS=E |
Report Facts
Census: 87
Total Capacity: 105
Staffing Deficient Days: 4
Deficiency Count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Left medication unattended at Resident #5's bedside |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Acknowledged medication cream left at Resident #56's bedside |
| Licensed Practical Nurse #2 | Nursing Supervisor | Observed not wearing gown while administering PEG tube medications to Resident #27 |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Observed not wearing gown while performing PEG tube care for Resident #27 |
| Social Services Director | Social Services Director | Responsible for Advance Directive documentation; acknowledged incomplete records |
| Administrator | Facility Administrator | Confirmed medication left unattended and incomplete Advance Directive documentation |
| Dietary Cook #2 | Dietary Cook | Failed to sanitize thermometer properly during food temperature checks |
| Dietary Manager | Dietary Manager | Confirmed improper thermometer sanitation and provided staff training |
| Licensed Practical Nurse #1 | Staffing Coordinator | Reported staffing challenges and confirmed staffing grid accuracy |
| Licensed Practical Nurse #6 | Infection Preventionist | Stated expectation for staff to don PPE for Enhanced Barrier Precautions |
Inspection Report
Annual Inspection
Census: 85
Capacity: 180
Deficiencies: 5
Jan 30, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 1/27/25 through 1/30/25 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 with staffing requirements, residents' rights, medication labeling and security, safe food handling, and infection control standards. Specific deficiencies included insufficient nursing staff on multiple days, failure to maintain a homelike environment due to torn flooring, medications left unsecured at bedside, improper food thermometer sanitation, and failure to follow enhanced barrier precautions for infection control.
Complaint Details
Complaint investigations were conducted for medication administration and quality of care (no citations), staffing, grooming, weight loss, bowel and bladder, and falls (M225 cited), and sufficient staffing levels (M225 cited).
Severity Breakdown
Level II: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure sufficient nursing staff to meet resident needs on four of 14 staffing days reviewed in January 2025. | Level II |
| Failed to ensure residents' right to a homelike environment due to torn and buckling flooring in Resident #5's room. | Level II |
| Failed to ensure medications were secured and inaccessible to unauthorized residents and staff; medications were left unattended at bedside for Residents #5 and #56. | Level II |
| Failed to ensure proper food handling and sanitation practices; dietary cook failed to sanitize thermometer properly when checking food temperatures. | Level II |
| Failed to ensure Enhanced Barrier Precautions were followed while providing care to Resident #27 requiring high-contact precautions. | Level II |
Report Facts
Staffing days with insufficient nursing staff: 4
Resident census during staffing review: 85
Licensed capacity: 180
BIMS score: 8
BIMS score: 15
BIMS score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Staffing Coordinator | Interviewed regarding staffing challenges and confirmed staffing grid accuracy. |
| Licensed Practical Nurse #5 | Confirmed medication left unattended and staffing shortages impacting care. | |
| Administrator | Interviewed regarding staffing shortages due to COVID-19 and call-ins, and awareness of torn flooring and medication issues. | |
| Maintenance Director | Responsible for facility maintenance; acknowledged delayed flooring repairs. | |
| Licensed Practical Nurse #3 | Acknowledged medication cups left at bedside. | |
| Dietary Cook #2 | Observed failing to properly sanitize thermometer. | |
| Dietary Manager #1 | Confirmed proper thermometer sanitation procedures and staff training. | |
| Licensed Practical Nurse #2 | Nursing Supervisor | Observed not wearing gown during PEG tube medication administration; acknowledged error. |
| Licensed Practical Nurse #7 | Observed not wearing gown during PEG tube care; acknowledged error. | |
| Licensed Practical Nurse #6 | Infection Preventionist | Explained importance of gown use for Enhanced Barrier Precautions and risks of noncompliance. |
Inspection Report
Annual Inspection
Census: 85
Capacity: 180
Deficiencies: 5
Jan 30, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 2025-01-27 through 2025-01-30 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 with staffing requirements, residents' rights, medication labeling and security, safe food handling, and infection control standards. Specific deficiencies included insufficient nursing staff on multiple days, failure to maintain a homelike environment due to torn flooring, medications left unsecured at bedside, improper food thermometer sanitation, and failure to follow Enhanced Barrier Precautions during resident care.
Complaint Details
Complaint investigations were conducted for medication administration and quality of care (no citations), staffing, grooming, weight loss, bowel and bladder, falls (M225 cited), and sufficient staffing levels (M225 cited).
Severity Breakdown
Level II: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure sufficient nursing staff to meet resident needs on four of fourteen staffing days in January 2025. | Level II |
| Failed to ensure residents' right to a homelike environment due to torn and buckling flooring in Resident #5's room. | Level II |
| Failed to ensure medications were secured and inaccessible to unauthorized residents and staff; medications left unattended at bedside for Residents #5 and #56. | Level II |
| Failed to ensure proper food handling and sanitation; Dietary Cook failed to sanitize thermometer properly causing cross-contamination risk. | Level II |
| Failed to ensure Enhanced Barrier Precautions were followed during care of Resident #27 requiring high-contact precautions; staff did not wear gowns as required. | Level II |
Report Facts
Staffing days with deficiencies: 4
Resident census: 85
Facility capacity: 180
Deficiency citations: 5
BIMS score: 8
BIMS score: 15
BIMS score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Staffing Coordinator | Interviewed regarding staffing challenges and confirmed staffing grid accuracy. |
| Licensed Practical Nurse #5 | Confirmed medication left unattended and staffing shortages affecting care. | |
| Administrator | Interviewed regarding staffing shortages due to COVID-19 and call-ins, and medication and flooring issues. | |
| Maintenance Director | Responsible for facility upkeep; acknowledged delayed flooring repairs. | |
| Licensed Practical Nurse #2 | Nursing Supervisor | Observed not wearing gown during PEG tube medication administration; acknowledged error. |
| Licensed Practical Nurse #7 | Observed not wearing gown during PEG tube care; acknowledged error. | |
| Licensed Practical Nurse #6 | Infection Preventionist | Interviewed regarding proper PPE use and infection control expectations. |
| Dietary Cook #2 | Observed failing to properly sanitize thermometer, causing cross-contamination risk. | |
| Dietary Manager #1 | Interviewed regarding proper thermometer sanitation procedures. |
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 1
Jan 28, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically regarding smoke barrier wall ratings and construction standards.
Findings
The facility failed to provide the required half hour fire rating in the smoke barrier walls, with unsealed holes around data cables observed in two smoke compartments, affecting four of six compartments and 54 residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide half hour rating in the smoke barrier wall in accordance with NFPA 101 sections 19.3.7.3 and 8.5.6.2, with unsealed holes around data cables at Central and North Hall smoke barrier walls. |
Report Facts
Residents affected: 54
Smoke compartments affected: 4
Inspection Report
Life Safety
Census: 54
Deficiencies: 3
Jan 28, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) and emergency preparedness requirements, focusing on smoke barrier construction, smoke barrier doors, and gas equipment storage.
Findings
The facility failed to provide the required half-hour fire resistance rating for smoke barrier walls and 20-minute fire resistance rating for smoke barrier doors, affecting multiple smoke compartments and 54 residents. Additionally, improper storage of oxygen cylinders was observed. Corrective actions and monitoring plans were outlined.
Severity Breakdown
SS=F: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide half-hour fire resistance rating in smoke barrier walls, with unsealed holes around data cables in Central and North smoke barrier walls. | SS=F |
| Failed to provide 20-minute fire resistance rating smoke barrier doors; doors did not close properly to resist smoke passage in South Station Hall and Central Station Hall. | SS=F |
| Failed to properly store oxygen cylinders; empty oxygen cylinder was not placed in proper storage container. | SS=D |
Report Facts
Residents affected: 54
Smoke compartments affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | In-serviced Maintenance Director and nursing staff; acknowledged findings | |
| Maintenance Director | Conducted rounds and visual checks of smoke barrier walls and doors; placed empty oxygen cylinder in proper storage; verified observations during exit interview | |
| Administrator | Acknowledged findings during exit interview | |
| Maintenance Supervisor | Verified observations during exit interview | |
| Central Supply aide | Conducted checks of respiratory storage area |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 17, 2024
Visit Reason
The State Agency conducted a complaint investigation regarding low staffing and cold foods at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint MS #26240 was investigated regarding low staffing and cold foods; the complaint was not substantiated as no deficiencies were found.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 105
Deficiencies: 0
Sep 17, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26240, regarding allegations of low staffing and cold foods at the facility.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint Investigation MS #26240 was investigated regarding low staffing and cold foods; the complaint was not substantiated as no deficiencies were cited.
Report Facts
Licensed beds: 105
Census: 86
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 2, 2024
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2024-05-22 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 2024-07-01.
Complaint Details
The visit was complaint-related, reviewing a complaint survey from 2024-05-22. The facility was found compliant and the complaint was effectively resolved.
Report Facts
Complaint survey date: May 22, 2024
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 2, 2024
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2024-05-22 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were implemented to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-07-01.
Complaint Details
The visit was related to a complaint survey completed on 2024-05-22. The facility's corrective actions were reviewed and found satisfactory, leading to a recommendation for compliance reinstatement.
Inspection Report
Complaint Investigation
Census: 90
Capacity: 105
Deficiencies: 1
May 22, 2024
Visit Reason
The State Agency conducted a complaint investigation from 5/19/24 through 5/22/24 regarding multiple complaints involving allegations of employee to resident abuse, quality of care related to call lights, services not provided, staffing, incontinent care, administration, and dietary services.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing a deficiency related to resident rights. Although abuse allegations were not substantiated, it was determined that residents were not treated with dignity and respect by nursing staff during procedures and medication administration for two residents. The facility took corrective actions including reassigning the nurse and providing staff in-service training.
Complaint Details
The complaint investigation involved five complaint investigations (CI MS #25028, #24916, #24971, #24816, and #24480). Allegations included employee to resident abuse, quality of care issues related to call lights, services not provided, staffing, incontinent care, administration, and dietary services. The abuse allegations were not substantiated, but dignity and respect issues were found.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure nursing staff treated residents with respect and dignity during procedures and medication administration for two residents. | SS=D |
Report Facts
Licensed beds: 105
Resident census: 90
Deficiency cited: 1
Resident sample size: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in findings related to disrespectful and demanding behavior toward residents #5 and #6 |
| Executive Director | Interviewed residents #5 and #6 regarding allegations | |
| Director of Nursing | Director of Nursing | Provided in-service training to LPN #1 and monitored corrective actions |
| Staff Development Coordinator | Provided competency training and in-service on resident rights and customer service | |
| Unit Manager (LPN #2) | Unit Manager | Interviewed regarding resident concerns about LPN #1 |
| Administrator | Administrator | Addressed complaints about LPN #1 and confirmed reassignment of nurse |
| Resident Representative | Provided information about resident complaints and interactions with staff |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 22, 2024
Visit Reason
The State Agency conducted a Complaint Investigation from 5/19/24 through 5/22/24 regarding multiple complaint investigations involving allegations of employee to resident abuse, quality of care related to call lights, services not provided, staffing, incontinent care, administration, and dietary services.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements related to residents' rights. Although allegations of abuse were not substantiated, it was determined that nursing staff failed to treat residents with dignity and respect during procedures and medication administration for two residents. The facility took corrective actions including reassigning the nurse and providing staff in-service training.
Complaint Details
The complaint investigation involved multiple complaint IDs (MS #25028, #24916, #24971, #24816, #24480). Allegations included employee to resident abuse, quality of care issues, staffing, and dietary services. The abuse allegations were not substantiated but residents were found not treated with dignity and respect. Specific complaints involved Licensed Practical Nurse #1's disrespectful and demanding behavior toward Residents #5 and #6, causing anxiety and discomfort. The facility investigated and reassigned the nurse and provided training.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure nursing staff treated residents with respect and dignity during procedures and medication administration for two residents. | Level II |
Report Facts
Complaint Investigation Dates: 4
Residents Sampled: 8
Performance Monitoring Frequency: 3
Performance Review Frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in findings for disrespectful and demanding behavior toward residents #5 and #6; reassigned to another unit and received in-service training. |
| Director of Nursing | Director of Nursing | Provided in-service training to LPN #1 and responsible for monitoring LPN #1's performance. |
| Executive Director | Executive Director | Interviewed residents and involved in addressing complaints. |
| Unit Manager (LPN #2) | Unit Manager | Confirmed prior concerns about LPN #1 from Resident #5. |
| Administrator | Administrator | Addressed complaints about LPN #1 and confirmed reassignment of LPN #1 to another hall. |
| Staff Development Coordinator | Staff Development Coordinator | Provided competency training and in-service on resident rights and customer service. |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 5, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 3/05/24 related to a complaint survey conducted from 1/25/24 through 1/26/24.
Findings
The State Agency found the facility to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements and recommends the facility be placed back in compliance effective 3/01/24.
Complaint Details
The visit was related to a complaint survey conducted from 1/25/24 through 1/26/24. The facility was found to be in compliance upon follow-up.
Inspection Report
Follow-Up
Census: 88
Capacity: 105
Deficiencies: 0
Mar 5, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 3/05/24 related to a complaint survey conducted from 1/25/24 through 1/26/24.
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 3/01/24.
Complaint Details
The visit was related to a complaint survey conducted from 1/25/24 through 1/26/24. The facility was found to be in compliance upon follow-up.
Report Facts
Licensed beds: 105
Census: 88
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 4, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 03/04/2024 related to quality of care issues including untimely response to call lights, care/services not received per physician instructions, residents left wet or soiled for extended periods, lack of repositioning, no pressure sore precautions, and resident neglect related to pressure sores.
Findings
During the survey, the facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited during this investigation, but the facility remains out of compliance due to deficiencies cited on a prior survey dated 01/26/2024.
Complaint Details
Two complaint investigations (CI MS #24202 and CI MS #24256) were conducted. CI MS #24202 involved quality of care issues related to call light response and care per physician instructions. CI MS #24256 involved quality of care issues related to residents being left wet, soiled, not repositioned, lack of pressure sore precautions, and resident neglect related to pressure sores. The complaints were investigated and no deficiencies were cited.
Report Facts
Complaint Investigation Numbers: 2
Prior survey date: Jan 26, 2024
Inspection Report
Complaint Investigation
Census: 87
Capacity: 105
Deficiencies: 0
Mar 4, 2024
Visit Reason
The State Agency conducted two complaint investigations on 3/04/2024 related to quality of care/treatment issues including timely answering of call lights, care/services not received per physician instructions, residents left wet or soiled for extended periods, lack of repositioning, no pressure sore precautions, and resident neglect related to pressure sores.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited for these complaint investigations. However, the facility remains out of compliance due to deficiencies cited in a prior survey dated 1/26/2024.
Complaint Details
Two complaint investigations (CI MS #24202 and CI MS #24256) were conducted. CI MS #24202 investigated quality of care related to call light response and care per physician instructions. CI MS #24256 investigated quality of care related to residents being left wet, soiled, not repositioned, lack of pressure sore precautions, and resident neglect related to pressure sores. No deficiencies were cited from these investigations.
Report Facts
Licensed beds: 105
Census: 87
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 26, 2024
Visit Reason
The State Agency conducted four complaint investigations from 1/25/24 through 1/26/24 at the facility for Quality of Care/Treatment, Facility Staffing, Resident Rights, and Neglect.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, with cited deficiencies related to call lights not being within reach for residents and failure to provide timely assistance with activities of daily living, including incontinent care and transfers.
Complaint Details
Four complaint investigations (CI MS #23961, CI MS #23922, CI MS #23923, and CI MS #23924) were conducted related to Quality of Care/Treatment, Facility Staffing, Resident Rights, and Neglect. The facility was found out of compliance with repeat deficiencies.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure call lights were within reach for three of five sampled residents (Residents #3, #4, and #5). | Level II |
| Failed to ensure dependent residents received necessary assistance with activities of daily living, including grooming and personal hygiene, for one of five residents reviewed (Resident #1). | Level II |
Report Facts
Number of complaint investigations: 4
Number of residents with call light deficiency: 3
Number of residents reviewed for ADL deficiency: 5
Wait time for assistance: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | CNA | Assigned to care of Resident #3; confirmed call lights should be within reach. |
| Director of Nurses | DON | Interviewed and confirmed expectation that call lights be within reach and answered timely. |
| Certified Nursing Assistant #1 | CNA | Assisted Resident #1 with transfer and incontinent care; involved in delayed response. |
| Certified Nursing Assistant #2 | CNA | Assisted Resident #1 with transfer and incontinent care. |
| Licensed Practical Nurse #1 | LPN | Entered Resident #1's room with medication and turned off call light during delay. |
| Executive Director | Executive Director | Reviewed security footage and confirmed delay in assistance to Resident #1. |
| Staff Development Nurse | Staff Development Nurse | Initiated in-service training regarding call light placement and ADL assistance. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 105
Deficiencies: 3
Jan 26, 2024
Visit Reason
The State Agency conducted four complaint investigations from 1/25/24 through 1/26/24 for Quality of Care/Treatment, Facility Staffing, Resident Rights, and Neglect.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to deficiencies related to call lights not being within reach for residents, failure to implement comprehensive care plans, and failure to provide necessary assistance with activities of daily living, including incontinent care and transfers.
Complaint Details
Four complaint investigations (CI MS #23961, CI MS #23922, CI MS #23923, and CI MS #23924) were conducted related to Quality of Care/Treatment, Facility Staffing, Resident Rights, and Neglect. The facility was found out of compliance due to repeat and new deficiencies.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure call lights were within reach for three of five sampled residents (Residents #3, #4, and #5). | SS=E |
| Failed to develop and implement comprehensive person-centered care plans for four of five sampled residents (Residents #1, #3, #4, and #5). | SS=E |
| Failed to ensure dependent residents received necessary services to maintain good grooming and personal hygiene for one of five residents reviewed (Resident #1). | SS=D |
Report Facts
Licensed beds: 105
Resident census: 93
Deficiency count: 3
Wait time for assistance: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | CNA | Assigned to care of Resident #3; confirmed call lights should be within reach |
| Director of Nurses | DON | Interviewed regarding expectations for call light placement and care plan adherence |
| Executive Director | Interviewed regarding care plan adherence and reviewed security footage related to Resident #1's care delay | |
| Certified Nursing Assistant #1 | CNA | Observed assisting Resident #1 with transfer and incontinent care |
| Certified Nursing Assistant #2 | CNA | Observed assisting Resident #1 with transfer |
| Licensed Practical Nurse #1 | LPN | Observed entering Resident #1's room with medication and turning off call light |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 11, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #23781) related to quality of care regarding notification and neglect related to assessment and monitoring.
Findings
During the survey, the facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Complaint Details
Complaint Investigation CI MS #23781 was related to quality of care regarding notification and neglect related to assessment and monitoring. The complaint was not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 105
Deficiencies: 0
Jan 11, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS 23781) regarding quality of care related to notification and neglect related failure to assessment and monitoring.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint Investigation CI MS 23781 was investigated regarding quality of care related to notification and neglect related failure to assessment and monitoring; no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 5, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI #23353) from 12/04/23 through 12/05/23 related to Quality of Care/Treatment issues including body odor, inadequate grooming, residents left wet or soiled for extended periods, neglect related to pressure sores, resident rights, and misappropriation of resident property/clothing.
Findings
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically fingernail care, for two of four sampled residents, Resident #1 and Resident #2, who had long, dirty fingernails. Additionally, the facility failed to ensure secure storage of medication, resulting in Resident #1 ingesting zinc oxide ointment intended for topical use. Corrective actions were implemented and the medication storage deficiency was determined to be Past Non-Compliance and corrected prior to the survey.
Complaint Details
Complaint Investigation MS #23353 was substantiated for Quality of Care/Treatment issues including inadequate grooming and neglect related to pressure sores. The medication storage deficiency was Past Non-Compliance and corrected prior to the survey.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate fingernail care for residents dependent on staff, evidenced by long, dirty fingernails with substances under nails for Resident #1 and Resident #2. | Level II |
| Failure to ensure secure storage of medication, resulting in Resident #1 ingesting zinc oxide ointment left unattended at bedside. | Level II |
Report Facts
Residents sampled for ADL care: 4
Amount of zinc oxide ingested: 5
Fingernails observed on Resident #2: 10
BIMS score for Resident #1: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Fed zinc oxide ointment to Resident #1; removed from duty and not allowed to return. |
| Director of Nursing Services | Director of Nursing Services | Responded to zinc oxide ingestion incident, conducted resident assessment, contacted Poison Control, and implemented in-service training. |
| Wound Care Nurse | Wound Care Nurse | Confirmed fingernail care standards and risks; confirmed medication storage policies and in-service training. |
| CNA #1 | Certified Nurse Aide | Reported zinc oxide ingestion incident and confirmed fingernail care expectations. |
| LPN #3 | Licensed Practical Nurse | Documented report of zinc oxide ingestion incident. |
| LPN #4 | Licensed Practical Nurse | Received in-service training on medication storage and securement. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 105
Deficiencies: 2
Dec 5, 2023
Visit Reason
The State Agency conducted a complaint investigation from 12/04/23 through 12/05/23 related to quality of care/treatment issues including body odor, inadequate grooming, residents left wet or soiled for extended periods, neglect related to pressure sores, resident rights, and misappropriation of resident property/clothing.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in Activities of Daily Living (ADL) care for dependent residents, specifically inadequate fingernail care for two residents, and failure to securely store medications, evidenced by a resident ingesting zinc oxide ointment left unattended. Corrective actions were implemented prior to the survey.
Complaint Details
Complaint Investigation MS #23353 was substantiated with findings related to quality of care including neglect and improper medication storage. The facility was cited for deficiencies F677 and F761. The zinc oxide ingestion incident involved a CNA feeding the ointment to a resident, leading to immediate corrective actions including removal of the CNA, staff in-service training, and audits.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide adequate fingernail care for dependent residents, with two residents observed having long, dirty fingernails. | SS=D |
| Failed to ensure secure storage of medications, resulting in a resident ingesting zinc oxide ointment left unattended at bedside. | SS=D |
Report Facts
Deficiencies cited: 2
Beds licensed: 105
Residents present: 84
Zinc oxide ingested: 5
Audit frequency: 3
Audit duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Fed zinc oxide ointment to Resident #1; removed from duty following incident. |
| Director of Nursing Services | Director of Nursing | Conducted resident assessment after zinc oxide ingestion, initiated corrective actions and staff training. |
| Wound Care Nurse | Provided information on fingernail care and medication storage policies. | |
| CNA #1 | Certified Nursing Assistant | Reported zinc oxide ingestion incident. |
| LPN #3 | Licensed Practical Nurse | Documented report of zinc oxide ingestion incident. |
| LPN #4 | Licensed Practical Nurse | Received in-service training on medication storage. |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 24, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 09/14/2023 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance based on the information provided, and the State Agency recommended the facility be placed back in compliance effective 10/20/2023.
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 24, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-09-14 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, and the State Agency recommended the facility be placed back in compliance effective 2023-10-20.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 24, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 09/14/23 to verify corrective measures taken by the facility.
Findings
The information provided confirmed that the facility had implemented measures to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 10/20/23.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 24, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 09/14/23 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 10/20/23.
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 14, 2023
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI), MS #22398, at the facility from 09/12/23 through 09/14/23. The investigation was related to facility staffing, call bell response, care per physician orders, dietary services, resident rights, and physical environment concerns including offensive odors.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. Deficiencies included failure to maintain an odor-free environment, improper use of physical restraints (full-length bed rails without physician orders), inadequate respiratory care practices, improper infection control related to disposal of soiled dressings, and failure to prevent infection risks related to respiratory tubing handling.
Complaint Details
Complaint Investigation MS #22398 was conducted related to facility staffing, call bell response, care per physician orders, dietary services, resident rights, and physical environment issues including offensive odors.
Severity Breakdown
Level II: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Residents were exposed to strong urine odors in hallways and biohazard rooms due to trash and laundry buildup. | Level II |
| A resident was physically restrained with full-length bed rails without physician order, consent, or proper evaluation. | Level II |
| Respiratory services were not provided properly, including oxygen tubing and CPAP tubing being placed on the floor, risking infection. | Level II |
| Soiled dressings were improperly disposed of in resident trash cans instead of red biohazard bags, risking infection spread. | Level II |
Report Facts
Days of survey: 3
Sampled residents: 21
Residents affected by restraint deficiency: 1
Residents reviewed for respiratory conditions: 2
Residents affected by infection control deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Noted urine odor source and improper CPAP tubing handling |
| Housekeeping Supervisor | Reported trash buildup causing odors in biohazard rooms | |
| Certified Nursing Assistant #4 | CNA | Reported trash removal practices in biohazard rooms |
| Director of Nursing | DON | Interviewed regarding restraint use, respiratory care, and infection control deficiencies |
| Certified Nursing Assistant #1 | CNA | Observed placing oxygen tubing from floor onto resident without proper cleaning |
| Licensed Practical Nurse #2 | LPN | Observed improper disposal of soiled dressings in resident trash can |
| Registered Nurse #2 | RN/Nurse Manager | Assisted with wound care and confirmed infection control protocols |
Inspection Report
Annual Inspection
Census: 91
Capacity: 105
Deficiencies: 4
Sep 14, 2023
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigation related to facility staffing, call bell response, care per physician orders, dietary services, resident rights, and physical environment issues including offensive odors.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to safe and clean environment, residents' rights to be free from physical restraints, respiratory care, and infection prevention and control.
Complaint Details
Complaint investigation MS #22398 related to facility staffing, call bell response, care per physician orders, dietary services, resident rights, and physical environment issues including offensive odors.
Severity Breakdown
SS=E: 1
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide an environment free of urine odor in two of three halls (Central and North Halls). | SS=E |
| Facility failed to ensure a resident was free from physical restraints related to use of full-length bed rails for one resident. | SS=D |
| Facility failed to provide respiratory care in a manner to prevent complications for two residents, including improper handling of CPAP and oxygen tubing. | SS=D |
| Facility failed to prevent the spread of infections by placing soiled dressings in resident's trash instead of red biohazard bags for one resident. | SS=D |
Report Facts
Facility licensed capacity: 105
Census: 91
Residents sampled for physical restraints: 21
Residents reviewed for respiratory conditions: 2
Residents sampled for infection control: 21
Mental Status Interview Score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed strong urine odor in hallways and improper CPAP tubing handling. |
| Housekeeping Supervisor | Reported odor caused by trash buildup in biohazard rooms. | |
| Certified Nursing Assistant #4 | CNA | Reported odors in hallways and trash removal duties. |
| Administrator | Acknowledged strong urine odors in facility. | |
| Director of Nursing | DON | Evaluated restraint use, confirmed no physician order for full-length bed rails, assessed residents, and confirmed infection control issues. |
| Unit Manager | Notified physician and resident representative about restraint changes and updated care plan. | |
| Licensed Practical Nurse #2 | LPN | Discarded soiled dressings improperly in resident's trash. |
| Registered Nurse #2 | RN/Nurse Manager | Confirmed proper disposal of medical waste in red biohazard bags. |
| Certified Nursing Assistant #1 | CNA | Handled oxygen tubing improperly by placing tubing from floor directly on resident. |
Inspection Report
Life Safety
Deficiencies: 0
Sep 14, 2023
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
Sep 14, 2023
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: 2
Sep 14, 2023
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation related to facility staffing, call bell response, care per physician orders, dietary services, resident rights, and physical environment issues including offensive odors.
Findings
The facility was found not in compliance with state licensure requirements, citing issues with resident rights, restraints, oxygen tubing, and infection control. Specifically, strong urine odors were noted in hallways and biohazard rooms, and a resident was found restrained with full-length bed rails without proper physician orders or documentation.
Complaint Details
Complaint Investigation MS #22398 was related to facility staffing, call bell response, care per physician orders, dietary services, resident rights regarding dignity and respect, and offensive odors in the facility.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents were exposed to strong urine odors in Central and North hallways and biohazard rooms due to trash and laundry buildup. | Level II |
| A resident was physically restrained with full-length bed rails without a physician's order, proper evaluation, or informed consent. | Level II |
Report Facts
Days with urine odor observed: 3
Sampled residents: 21
Residents with restraint issue: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed strong urine odor in hallways and attributed it to trash and laundry buildup. |
| Housekeeping Supervisor | Reported trash and laundry buildup in biohazard rooms causing odors. | |
| Certified Nurse Aide #4 | CNA | Reported removing trash from biohazard rooms and checking trash every 2 hours. |
| Administrator | Facility Administrator | Acknowledged noticing strong urine odors intermittently over the past year and a half. |
| Director of Nursing | DON | Acknowledged Resident #22 had full-length bed rails but did not consider them restraints; confirmed no physician order for bed rails. |
Inspection Report
Annual Inspection
Census: 91
Capacity: 105
Deficiencies: 1
Sep 14, 2023
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation related to facility staffing, call bell response times, care per physician orders, dietary services, resident rights, and physical environment issues including offensive odors.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies including failure to provide a safe, clean, comfortable, and homelike environment due to strong urine odors in two of three facility halls (Central and North Halls).
Complaint Details
Complaint Investigation MS #22398 was related to facility staffing, call bell not answered timely, care not received per physician orders, dietary services, resident rights related to dignity and respect, and physical environment related to offensive odors.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide an environment free of urine odor for two of three facility halls (Central Hall and North Hall). | SS=E |
Report Facts
Facility licensed capacity: 105
Census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed strong urine odor in Central and North hallways and attributed odor to trash and laundry buildup in biohazard rooms |
| Housekeeping Supervisor | Housekeeping Supervisor | Reported odor caused by trash buildup in biohazard rooms and described housekeeping procedures |
| CNA #4 | Certified Nurse Aide | Noticed odors in hallways when laundry and trash built up in biohazard rooms and described trash removal practices |
| Administrator | Administrator | Confirmed noticing strong urine odors intermittently during her tenure and acknowledged unpleasantness for residents |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints from 5/15/23 through 5/16/23 related to Quality of Care/Treatment including timing of resident medications, resident abuse, answering the call bell, incontinent care, and accidents related to an unwitnessed fall.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited during the investigation.
Complaint Details
The investigation involved two complaints: CI MS #21102 concerning Quality of Care/Treatment related to timing of resident medications and resident abuse, and CI MS #21415 concerning Quality of Care/Treatment related to answering the call bell, incontinent care, and accidents related to an unwitnessed fall. Both complaints were investigated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 105
Deficiencies: 0
May 16, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints related to quality of care/treatment, including timing of resident medications, resident abuse, answering the call bell, incontinent care, and accidents related to unwitnessed falls.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited related to the complaints investigated.
Complaint Details
The investigation covered two complaints: CI MS #21102 regarding timing of resident medications and resident abuse, and CI MS #21415 regarding answering the call bell, incontinent care, and accidents related to unwitnessed falls. No deficiencies were cited.
Report Facts
Licensed beds: 105
Resident census: 94
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 22, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for three complaints involving alleged neglect of a resident, failure to answer the facility telephone, poor quality of care by staff, odors of feces and urine in the building, vomit on the floor, and staff refusing to assist a resident to use the restroom.
Findings
During the survey, the State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and cited no deficiencies.
Complaint Details
The investigation involved three complaints: MS #20872 for alleged neglect, MS #20876 for odors and vomit, and MS #21008 for staff refusing to assist a resident. The facility was found compliant with no deficiencies cited.
Report Facts
Number of complaints investigated: 3
Inspection Report
Complaint Investigation
Census: 96
Capacity: 105
Deficiencies: 0
Mar 22, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for three complaints involving alleged neglect of a resident, failure to answer the facility telephone, poor quality of care by staff, odors of feces and urine, vomit on the floor, and staff refusing to assist a resident with restroom use.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and cited no deficiencies.
Complaint Details
The investigation involved three complaints: MS #20872 for alleged neglect and poor quality of care, MS #20876 for odors and vomit in the building, and MS #21008 for staff refusing to assist a resident with restroom use. The facility was found compliant with no deficiencies cited.
Report Facts
Complaints investigated: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 29, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 12/27/22 to 12/29/22 regarding multiple complaint numbers MS #20277, MS #19735, and MS #19727.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for The Aged or Infirm. Complaints related to abuse, incontinent care, pressure sores, and roaches were not substantiated, and no deficiencies were cited.
Complaint Details
Complaint investigation included MS #20277 (not substantiated for abuse), MS #19735 (not substantiated for incontinent care, pressure sores, or roaches), and MS #19727 (not substantiated for incontinent care). No deficiencies cited.
Inspection Report
Complaint Investigation
Census: 88
Capacity: 105
Deficiencies: 0
Dec 29, 2022
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey and a Complaint Investigation at the facility from 12/27/22 to 12/29/22.
Findings
The facility was found to be in compliance with infection control regulations and Medicare and Medicaid participation requirements. No deficiencies were cited related to infection control or the complaint allegations, which were not substantiated.
Complaint Details
Complaint investigations MS #20277, MS #19735, and MS #19727 were not substantiated for abuse, incontinent care, pressure sores, or roaches, with no deficiencies cited.
Report Facts
Licensed beds: 105
Census: 88
Inspection Report
Routine
Deficiencies: 0
Dec 29, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted at the facility by the State Agency from 12/27/22 to 12/29/22 to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 29, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 12/27/22 to 12/29/22 regarding multiple complaint numbers MS #20277, MS #19735, and MS #19727.
Findings
The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for The Aged or Infirm. Complaints MS #20277, MS #19735, and MS #19727 were not substantiated, and no deficiencies were cited.
Complaint Details
Complaint MS #20277 was not substantiated for abuse; MS #19735 was not substantiated for incontinent care, pressure sores, or roaches; MS #19727 was not substantiated for incontinent care.
Report Facts
Complaint investigation dates: Investigation conducted from 12/27/22 to 12/29/22
Inspection Report
Complaint Investigation
Census: 88
Capacity: 105
Deficiencies: 0
Dec 29, 2022
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey and a Complaint Investigation at the facility from 12/27/22 to 12/29/22.
Findings
The facility was found to be in compliance with infection control regulations and Medicare and Medicaid participation requirements. No deficiencies were cited related to infection control or the complaints investigated, which were not substantiated.
Complaint Details
Complaint investigations MS #20277, MS #19735, and MS #19727 were not substantiated for abuse, incontinent care, pressure sores, roaches, or incontinent care, with no deficiencies cited.
Report Facts
Licensed beds: 105
Census: 88
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 21, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 10/20/22 through 10/21/22 regarding complaints MS #19677 and MS #18675.
Findings
The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. The complaints regarding incontinence care, following physician orders, staffing, and resident neglect were not substantiated. No deficiencies were cited.
Complaint Details
Complaint Investigation MS #19677 and MS #18675 were not substantiated. Complaints involved incontinence care, following physician orders, staffing, and resident neglect.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 105
Deficiencies: 0
Oct 21, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 10/20/22 through 10/21/22 related to complaints MS #19677 and MS #18675 regarding incontinence care, following physician orders, staffing, and resident neglect.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints were not substantiated and no deficiencies were cited.
Complaint Details
Complaint investigation for MS #19677 and MS #18675 was conducted. The complaints regarding incontinence care, following physician orders, staffing, and resident neglect were not substantiated.
Report Facts
Licensed beds: 105
Census: 96
Inspection Report
Complaint Investigation
Census: 96
Capacity: 105
Deficiencies: 0
Oct 21, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 10/20/22 through 10/21/22 related to complaints MS #19677 and MS #18675.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints regarding incontinence care, following physician orders, staffing, and resident neglect were not substantiated. No deficiencies were cited.
Complaint Details
Complaints MS #19677 and MS #18675 were investigated and not substantiated.
Report Facts
Licensed beds: 105
Census: 96
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 18, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 3/16/22 through 3/18/22 related to multiple complaint survey numbers.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions For The Aged or Infirm. None of the complaints regarding pressure sores, infection control, physician orders not followed, family notification, hydration, or pressure sore prevention were substantiated, and no deficiencies were cited.
Complaint Details
The State Agency did not substantiate complaints MS #18571, MS #18417, MS #18335, and MS #18254 for issues including pressure sores, infection control, physician orders not followed, family notification, hydration, and pressure sore prevention.
Inspection Report
Complaint Investigation
Census: 90
Capacity: 105
Deficiencies: 0
Mar 18, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 3/16/22 through 3/18/22 related to multiple complaint survey numbers.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. None of the complaints regarding pressure sores, infection control, physician orders, family notification, hydration, or pressure sore prevention were substantiated and no deficiencies were cited.
Complaint Details
The State Agency did not substantiate complaints MS #18571, MS #18417, MS #18335, and MS #18254 for issues including pressure sores, infection control, physician orders not followed, family notification, and hydration.
Report Facts
Licensed beds: 105
Census: 90
Inspection Report
Follow-Up
Deficiencies: 0
Oct 15, 2021
Visit Reason
The State Agency conducted a follow-up/revisit survey on 10/15/21 for an annual and complaint survey completed from 8/9/21 through 8/13/21.
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 10/6/21.
Inspection Report
Follow-Up
Census: 87
Capacity: 105
Deficiencies: 0
Oct 15, 2021
Visit Reason
The State Agency conducted a follow-up/revisit survey on 10/15/21 for an annual survey with four complaint investigations.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid effective 10/6/21.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 15, 2021
Visit Reason
The State Agency conducted a follow-up/revisit survey on 10/15/21 for an annual and complaint survey completed from 8/9/21 through 8/13/21.
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 10/6/21.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 14, 2021
Visit Reason
The State Agency conducted three complaint investigations (CI #18149, #18007, and #18029) from 10/13/21 through 10/14/21.
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.
Complaint Details
Three complaint investigations were conducted, and the facility was found compliant.
Inspection Report
Complaint Investigation
Census: 91
Capacity: 105
Deficiencies: 0
Oct 14, 2021
Visit Reason
The State Agency conducted a complaint survey for Complaint Investigation (CI) #18149 regarding Resident Rights/denied visitation and Quality of Care/not giving medication according to physician instructions, CI #18007 for Admission, Transfer, & Discharge Rights, and CI #18029 for Quality of Care/staffing on 10/13/21 through 10/14/21.
Findings
The complaints investigated during the survey were unsubstantiated.
Complaint Details
Complaint Investigation (CI) #18149 for Resident Rights/denied visitation and Quality of Care/not giving medication according to physician instructions, CI #18007 for Admission, Transfer, & Discharge Rights, and CI #18029 for Quality of Care/staffing. Complaints were unsubstantiated.
Report Facts
Licensed beds: 105
Census: 91
Inspection Report
Annual Inspection
Census: 74
Capacity: 105
Deficiencies: 1
Aug 13, 2021
Visit Reason
An Annual Survey and four Complaint Investigations were conducted by the State Agency from 8/9/21 through 8/13/21 to assess compliance with infection control regulations and other standards.
Findings
The facility was found not in compliance with infection control regulations related to COVID-19 practices, specifically involving a meal tray contamination incident exposing a resident to potential COVID-19 infection. Several deficiencies were cited during the Annual Survey.
Complaint Details
Four complaint investigations were conducted (CI MS #17587, #17976, #17971, and #17967). Three were not substantiated. CI MS #17967 was substantiated for Infection Control related to the meal tray contamination incident.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent possible spread of infection when a resident was served a meal tray that had been on the contaminated COVID-19 Observation Unit meal cart. | SS=D |
Report Facts
Complaint Investigations: 4
Beds Licensed: 105
Census: 74
Meals Observed: 3
BIMS Score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in infection control deficiency for improperly serving a contaminated meal tray and not completing orientation. |
| LPN #2 | Infection Preventionist | Provided expert statements on infection control procedures and deficiency severity. |
| Interim Director of Nursing | Director of Nursing | Acknowledged infection control breach and resident risk. |
| LPN #4 | Staff Development/Human Resources | Provided information on agency staff orientation and in-service training. |
Inspection Report
Annual Inspection
Census: 74
Capacity: 105
Deficiencies: 2
Aug 13, 2021
Visit Reason
An Annual Survey and four Complaint Investigations were conducted from 8/9/21 through 8/13/21 to assess compliance with Minimum Standards of Operation and state licensure requirements.
Findings
The facility was found not in compliance with residents' rights related to bathing and visitation during a COVID-19 outbreak, and failed to prevent the spread of food-borne illness due to undercooked chicken served. Several residents reported not receiving showers per their preference and visitation was suspended due to COVID-19. The facility took corrective actions including staff in-service and monitoring.
Complaint Details
Four complaint investigations were conducted; three were not substantiated and one was substantiated for Infection Control with deficiency cited at the Federal level.
Severity Breakdown
Level II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to honor residents' rights by not providing showers per choice and failed to honor residents' rights for visitation for seven of 18 residents sampled during a COVID-19 outbreak. | Level II |
| Failed to prevent the spread of food-borne illness by serving undercooked fried chicken to residents. | — |
Report Facts
Census: 74
Total Capacity: 105
Complaint Investigations: 4
Vaccinated Residents: 72
County Positivity Rate: 16.5
BIMS Scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in relation to serving undercooked chicken and corrective actions taken | |
| Infection Preventionist (LPN #2) | Reported order to stop showers due to COVID-19 outbreak and acknowledged infection control risks | |
| Director of Nursing | Interviewed regarding shower stoppage and responsibility for ensuring showers were provided | |
| Administrator | Interviewed regarding visitation suspension and shower stoppage during COVID-19 outbreak |
Inspection Report
Routine
Deficiencies: 6
Aug 13, 2021
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements including resident rights, care planning, infection control, food safety, and discharge notification.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination regarding bathing preferences, failure to allow visitation during a COVID-19 outbreak, failure to notify residents or representatives in writing of hospital transfers, failure to follow comprehensive care plans for bathing preferences, failure to ensure food safety with undercooked chicken served, and failure to prevent possible spread of infection related to meal tray handling in COVID-19 units.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to honor residents' rights by not providing showers per choice for five residents. | SS=D |
| Facility failed to honor residents' rights for visitation for four family interviews during COVID-19 outbreak. | SS=D |
| Facility failed to notify resident or representative in writing of hospitalizations for four residents. | SS=D |
| Facility failed to follow comprehensive care plan by not providing showers per residents' preferences for five residents. | SS=D |
| Facility failed to prevent possible spread of food-borne illness by serving undercooked chicken to residents. | SS=D |
| Facility failed to prevent possible spread of infection by improper handling of meal trays in COVID-19 unit. | SS=D |
Report Facts
Residents affected by bathing choice deficiency: 5
Family interviews affected by visitation rights deficiency: 4
Residents with hospital notification deficiency: 4
Residents with bathing care plan deficiency: 5
Residents vaccinated for COVID-19: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in infection control finding for improper meal tray handling in COVID-19 unit |
| LPN #2 | Licensed Practical Nurse / Infection Preventionist | Named in bathing care plan and infection control findings |
| RN #1 | Registered Nurse / Previous Director of Nursing | Named in hospital notification deficiency |
| Dietary Manager | Named in food safety finding for serving undercooked chicken |
Inspection Report
Annual Inspection
Census: 74
Capacity: 105
Deficiencies: 1
Aug 13, 2021
Visit Reason
An Annual Survey and four Complaint Investigations were conducted by the State Agency from 08/09/2021 through 08/13/2021.
Findings
The facility was found not to be in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements at M500 and M815. Three complaint investigations were not substantiated, while one complaint investigation was substantiated for Infection Control with a deficiency cited at the Federal level.
Complaint Details
Four complaint investigations were conducted: CI MS #17587, CI MS #17976, CI MS #17971, and CI MS #17967. CI MS #17587, CI MS #17976, and CI MS #17971 were not substantiated. CI MS #17967 was substantiated for Infection Control.
Deficiencies (1)
| Description |
|---|
| Deficiency cited for Infection Control at the Federal level |
Report Facts
Complaint Investigations conducted: 4
Beds licensed: 105
Census: 74
Inspection Report
Life Safety
Deficiencies: 0
Aug 11, 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 with no deficiencies cited during this survey.
Inspection Report
Deficiencies: 0
Aug 11, 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. No deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 11, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from March 8, 2021 through March 11, 2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 105
Deficiencies: 0
Mar 11, 2021
Visit Reason
The State Agency conducted multiple complaint investigations related to Quality of Care, Physical Environment, Abuse/Neglect, Staffing, Dietary, Administration, and a COVID-19 survey from 03/08/21 through 03/11/21.
Findings
During the survey, the complaints were not substantiated and no deficiencies were cited, including no deficiencies related to the COVID-19 Focused Infection Control survey.
Complaint Details
Multiple complaint investigations were conducted for various concerns including Quality of Care, Abuse/Neglect, Staffing, Environmental, Dietary, and Administration. None of the complaints were substantiated.
Report Facts
Census: 89
Total licensed capacity: 105
Inspection Report
Complaint Investigation
Census: 89
Capacity: 105
Deficiencies: 0
Mar 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and multiple complaint investigations were conducted from 03/08/21 through 03/11/21 related to Quality of Care, Physical Environment, Abuse/Neglect, Staffing, Dietary, Environmental, Housekeeping, and Administration concerns.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. The State Agency did not substantiate the complaints during the survey.
Complaint Details
Multiple complaint investigations (CI MS 16580, 16975, 17104, 17107, 17254, 17255, 17506, 17508) were conducted related to Quality of Care, Abuse/Neglect, Staffing, Environmental, Dietary, Housekeeping, and Administration concerns. None of the complaints were substantiated.
Report Facts
Census: 89
Total licensed capacity: 105
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 11, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from March 8, 2021 through March 11, 2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 105
Deficiencies: 0
Mar 11, 2021
Visit Reason
The State Agency conducted multiple complaint investigations related to Quality of Care, Physical Environment, Abuse/Neglect, Staffing, Dietary, Administration, and a COVID-19 survey from 03/08/21 through 03/11/21.
Findings
During the survey, the complaints were not substantiated and no deficiencies were cited, including no deficiencies related to the COVID-19 Focused Infection Control survey.
Complaint Details
Multiple complaint investigations were conducted for various concerns including Quality of Care, Abuse/Neglect, Staffing, Environmental, Dietary, and Administration. None of the complaints were substantiated.
Inspection Report
Complaint Investigation
Census: 89
Capacity: 105
Deficiencies: 0
Mar 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted along with multiple complaint investigations related to Quality of Care, Physical Environment, Abuse/Neglect, Staffing, Dietary, Administration, and Housekeeping concerns from 03/08/21 through 03/11/21.
Findings
The facility was found to be in compliance with infection control regulations and implemented recommended COVID-19 practices. The State Agency did not substantiate the complaints during the survey.
Complaint Details
Multiple complaint investigations (CI MS 16580, 16975, 17104, 17107, 17254, 17255, 17506, 17508) were conducted from 03/08/21 through 03/11/21. The complaints were not substantiated by the State Agency.
Report Facts
Census: 89
Total licensed capacity: 105
Inspection Report
Routine
Census: 83
Capacity: 105
Deficiencies: 0
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 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 CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/29/2020 to assess compliance with federal regulations related to emergency preparedness.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Abbreviated Survey
Census: 83
Capacity: 105
Deficiencies: 0
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 to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/29/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 78
Capacity: 110
Deficiencies: 1
Nov 20, 2020
Visit Reason
The State Agency conducted a COVID-19 Infection Control survey along with complaint investigations from 10/12/2020 to 10/14/2020.
Findings
The facility was found not in compliance with Minimum Standards for the Aged or Infirm due to environmental concerns (M-1010). No deficiencies were cited related to the COVID-19 Focused Infection Control survey. Several complaints related to quality of care were not substantiated and had no deficiencies cited.
Complaint Details
Complaints MS #16607, MS #16711, MS #16738, MS #16791, and MS #16684 were investigated. Complaints MS #16607, MS #16711, MS #16738, and MS #16791 related to quality of care were not substantiated with no deficiencies cited.
Deficiencies (1)
| Description |
|---|
| Environmental concerns related to Minimum Standards for the Aged or Infirm (M-1010) |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 10/14/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 78
Capacity: 110
Deficiencies: 1
Oct 14, 2020
Visit Reason
The State Agency conducted a COVID-19 Infection Control survey along with complaint investigations (MS #16607, MS #16711, MS #16738, MS #16791, and MS #16684) from 10/12/2020 to 10/14/2020 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance due to environmental concerns related to unsafe, unclean, and uncomfortable conditions in resident care areas, including debris buildup, soiled floors, walls, doors, and privacy curtains in multiple resident rooms and hallways. No deficiencies were cited related to COVID-19 infection control or quality of care complaints. The facility failed to maintain a safe, clean, comfortable, and homelike environment in 14 of 110 resident rooms and all hallways inspected.
Complaint Details
The complaint investigation included multiple complaint numbers (MS #16607, MS #16711, MS #16738, MS #16791, and MS #16684). The State Agency did not substantiate complaints MS #16607, MS #16711, MS #16738, and MS #16791 related to quality of care, with no deficiencies cited. The deficiency cited was related to environmental concerns (F-684).
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide a safe, clean, comfortable and homelike environment in resident care areas, with debris buildup, soiled floors, walls, doorframes, and privacy curtains in multiple rooms and hallways. | SS=E |
Report Facts
Census: 78
Total licensed capacity: 110
Number of resident rooms with deficiencies: 14
Number of hallways with deficiencies: 3
Inspection Report
Routine
Deficiencies: 0
Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 78
Capacity: 110
Deficiencies: 1
Oct 14, 2020
Visit Reason
The State Agency conducted a COVID-19 Infection Control survey along with complaint investigations from 10/12/2020 to 10/14/2020 to determine compliance with Minimum Standards for the Aged or Infirm.
Findings
The facility was found not in compliance due to environmental concerns related to housekeeping and cleanliness in resident care areas, including buildup of debris, sticky substances on floors and walls, soiled doors and curtains, and overflowing trash in multiple resident rooms and hallways. No deficiencies were cited related to COVID-19 infection control or quality of care complaints.
Complaint Details
The survey included complaints MS #16607, MS #16711, MS #16738, MS #16791, and MS #16684. The complaints related to quality of care were not substantiated and no deficiencies were cited for those. The environmental concerns were substantiated.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide a safe, clean, comfortable and homelike environment in resident care areas with buildup of debris, sticky substances, soiled doors, and overflowing trash in multiple resident rooms and hallways. | Level II |
Report Facts
Census: 78
Total Capacity: 110
Number of affected resident rooms: 14
Number of hallways affected: 3
Number of units toured: 3
Inspection Report
Deficiencies: 1
Oct 14, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding providing a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to maintain a safe, clean, and homelike environment in resident care areas, with debris buildup, soiled floors, walls, doorframes, and furniture in multiple resident rooms and hallways. Housekeeping and maintenance deficiencies were noted, and corrective actions including cleaning, repairs, and staff in-service trainings were implemented.
Deficiencies (1)
| Description |
|---|
| Failure to provide a safe, clean, comfortable and homelike environment in resident care areas, including buildup of debris on floors, walls, doorframes, and soiled resident rooms and bathrooms. |
Report Facts
Resident rooms affected: 14
Units toured: 3
Hallways affected: 3
Frequency of environmental rounds: 5
Duration of environmental rounds: 4
Date of survey completion: Nov 13, 2020
Inspection Report
Complaint Investigation
Census: 78
Capacity: 110
Deficiencies: 1
Oct 12, 2020
Visit Reason
The State Agency conducted a COVID-19 Infection Control survey along with complaint investigations (MS #16607, MS #16711, MS #16738, MS #16791, and MS #16684) from 10/12/2020 to 10/14/2020 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance due to environmental concerns cited under F-684. Complaints MS #16607, MS #16711, MS #16738, and MS #16791 related to quality of care were not substantiated and no deficiencies were cited related to the COVID-19 Focused Infection Control survey.
Complaint Details
Complaints MS #16607, MS #16711, MS #16738, and MS #16791 related to quality of care were not substantiated. No deficiencies were cited related to these complaints or the COVID-19 Focused Infection Control survey.
Deficiencies (1)
| Description |
|---|
| Environmental concerns related to F-684 |
Inspection Report
Routine
Census: 76
Capacity: 105
Deficiencies: 0
Sep 17, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and 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 CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 76
Capacity: 105
Deficiencies: 0
Sep 17, 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
Complaint Investigation
Deficiencies: 0
Jul 8, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 7/8/2020.
Findings
The investigation was unsubstantiated with no deficiencies cited for Neglect, Physician Services, Quality of Care, Accidents, and Physical Environment. The facility was determined to be in compliance with Medicare and Medicaid requirements for participation.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 79
Capacity: 105
Deficiencies: 0
May 27, 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.
Report Facts
Census: 79
Total licensed capacity: 105
Inspection Report
Routine
Census: 79
Capacity: 105
Deficiencies: 0
May 27, 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: 79
Deficiencies: 0
May 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted 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 has implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR 483.83 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 16, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation at the facility on 1/16/2020.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Complaint Details
Complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 21, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation at the facility.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 28, 2019
Visit Reason
A complaint investigation was conducted at the facility on August 28, 2019.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 101
Capacity: 105
Deficiencies: 0
Apr 18, 2019
Visit Reason
A standard annual survey was conducted at Lakeland Nursing and Rehabilitation from April 15, 2019 through April 18, 2019 to assess compliance with Medicare/Medicaid participation requirements.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid requirements. No deficiencies were cited in the Life Safety Code survey or the emergency preparedness survey.
Report Facts
Facility census: 101
Total licensed capacity: 105
Inspection Report
Annual Inspection
Census: 101
Capacity: 105
Deficiencies: 0
Apr 18, 2019
Visit Reason
A standard survey was conducted at Lakeland Nursing and Rehabilitation from April 15, 2019 through April 18, 2019 to assess compliance with the Minimum Standards for the Aged and Infirmed.
Findings
The standard survey revealed that the facility was in substantial compliance with the requirements of participation in the Minimum Standards for the Aged and Infirmed.
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