Inspection Reports for
Landmark of DeSoto
3068 Nail Road West, Horn Lake, MS, 38637
Back to Facility Profile38 Reports
Inspection Report — Jun 10, 2026
Complaint Investigation
Date: Jun 10, 2026
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI) MS# 3030245 at the facility on 6/10/26.
Complaint Details
Complaint number CI MS# 3030245 was investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Apr 30, 2026
Follow-Up
Date: Apr 30, 2026
Visit Reason
On 4/30/26 the State Agency (SA) conducted an onsite revisit for a recertification survey completed on 3/17/26 through 3/19/26. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 4/22/26. No deficiencies were cited during this revisit survey.
Report Facts
Deficiencies cited: 0
Inspection Report — Mar 19, 2026
Annual Inspection
Date: Mar 19, 2026
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 3/17/26 through 3/19/26. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation and cited multiple deficiencies.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in areas including informed consent for psychotropic medications, reasonable accommodations, chemical restraints, accuracy of assessments, care plan revisions, range of motion, catheter care, medication errors, drug storage, and infection control.
Deficiencies (10)
F0552 - Right to be informed/make treatment decisions. The facility failed to ensure informed consent was obtained prior to the initiation of psychotropic medications for five residents reviewed.
F0558 - Reasonable accommodations needs/preferences. The facility failed to have the call light accessible for one resident reviewed.
F0605 - Right to be free from chemical restraints. The facility failed to ensure the physician reviewed and responded to pharmacy recommendations for gradual dose reduction and failed to ensure PRN psychotropic medication orders included a stop date for four residents reviewed.
F0641 - Accuracy of assessments. The facility failed to ensure the accuracy of resident assessments by inaccurately completing section H (bowel and bladder) of the Minimum Data Set for one resident reviewed.
F0657 - Care plan timing and revision. The facility failed to ensure the interdisciplinary team reviewed and revised the resident’s comprehensive care plan to reflect changes in the resident’s condition for one resident reviewed.
F0688 - Increase/prevent decrease in range of motion. The facility failed to provide services to maintain or improve range of motion by not ensuring a physician ordered splint was applied daily for one resident reviewed.
F0690 - Bowel/bladder incontinence, catheter, UTI. The facility failed to ensure proper positioning and management of an indwelling urinary catheter drainage system for one resident reviewed.
F0759 - Free of medication error rates 5 percent or more. The facility failed to ensure the medication error rate was five percent or less, with six medication errors out of thirty-three opportunities observed.
F0761 - Label/store drugs and biologicals. The facility failed to ensure insulins were properly stored in accordance with manufacturer's guidelines to maintain safety and effectiveness for one medication cart observed.
F0880 - Infection prevention and control. The facility failed to properly disinfect a glucometer after use and failed to ensure contact precautions were in place for one resident with an ESBL infection.
Report Facts
Deficiencies cited: 10
Medication error rate: 18.18
Inspection Report — Mar 17, 2026
Life Safety
Date: Mar 17, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Dec 22, 2025
Complaint Investigation
Date: Dec 22, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI #MS 2685552) at the facility on 12/22/25 and investigated resident neglect, activities of daily living, and quality of care.
Complaint Details
Complaint investigation CI #MS 2685552 regarding resident neglect, activities of daily living, and quality of care was conducted and found no deficiencies; the facility was in compliance.
Findings
The survey determined that the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 19, 2025
Complaint Investigation
Date: Aug 19, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI #497166) at the facility on 8/19/25.
Complaint Details
Complaint investigation CI #497166 was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Dec 31, 2024
Complaint Investigation
Date: Dec 31, 2024
Visit Reason
The State Agency conducted two complaint investigations (CI MS# 27167 and CI MS #27185) at the facility on 12/31/24.
Complaint Details
Two complaint investigations (CI MS# 27167 and CI MS #27185) were conducted and no deficiencies were cited; the facility was found in compliance.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services with no deficiencies cited.
Report Facts
Complaint investigations conducted: 2
Inspection Report — Nov 25, 2024
Follow-Up
Date: Nov 25, 2024
Visit Reason
The State Agency conducted a revisit survey at the facility on 11/25/24 related to the annual survey that was conducted 10/28/24 through 10/30/24.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and is recommended to be placed back in compliance effective 11/18/24.
Inspection Report — Nov 20, 2024
Life Safety
Date: Nov 20, 2024
Visit Reason
On 11/20/24 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 10/29/24. The facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The State Agency confirmed the facility had corrected the deficient practice and recommended the facility be placed back in compliance effective 11/18/24.
Inspection Report — Oct 30, 2024
Annual Inspection
Date: Oct 30, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/28/24 through 10/30/24. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F550, F578, F656, F686, F690, F755, F761 and F851.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies cited in resident rights, advance directives, care planning, pressure ulcer treatment, catheter care, pharmacy services, medication storage, and payroll-based journal staffing data submission.
Deficiencies (8)
F0550 - Resident Rights/Exercise of Rights. The facility failed to provide privacy for one resident who was left uncovered and visible from the hallway, compromising dignity.
F0578 - Request/Refuse/Discontinue Treatment; Formulate Advance Directive. The facility failed to honor a resident's right to make health care decisions related to cardiopulmonary resuscitation (CPR).
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop a comprehensive care plan for two residents with pressure ulcers, lacking pressure reduction interventions.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to provide treatment and services to prevent pressure ulcers for two residents, including lack of pressure relief devices and failure to monitor skin under immobilizer.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide appropriate catheter care, resulting in cross contamination during catheter cleaning for one resident.
F0755 - Pharmacy Services/Procedures/Pharmacist/Records. The facility failed to maintain a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for one narcotic storage area.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure a resident's environment was free from accident hazards, as medications were left unsecured at bedside for one resident.
F0851 - Payroll Based Journal. The facility failed to submit accurate staffing information into the payroll-based journal system for the third quarter of fiscal year 2024.
Report Facts
Deficiencies cited: 8
Inspection Report — Oct 30, 2024
Routine
Date: Oct 30, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, honoring resident rights regarding healthcare decisions, care planning for pressure ulcers, pressure ulcer prevention and treatment, catheter care, medication record reconciliation, medication storage, and accurate staffing data submission to CMS.
Deficiencies (8)
F 0550: The facility failed to provide privacy for Resident #17 who was left uncovered and visible from the hallway, violating dignity and respect policies.
F 0578: The facility failed to honor Resident #58's right to make healthcare decisions related to CPR, as the resident was not consulted and a family member signed the consent.
F 0656: The facility failed to develop a comprehensive care plan for Residents #28 and #209 with pressure ulcers, lacking measurable objectives and interventions.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for Residents #28 and #209, including lack of pressure relief devices and inadequate skin monitoring under immobilizer.
F 0690: The facility failed to provide appropriate catheter care for Resident #57, including improper cleaning technique leading to cross contamination risk.
F 0755: The facility failed to maintain accurate medication records for controlled substances, specifically Lorazepam in the medication room refrigerator, which was not reconciled every shift.
F 0761: The facility failed to ensure medications were stored securely, as Resident #58 had unsecured medications at bedside without physician orders or staff monitoring.
F 0851: The facility failed to submit accurate direct care staffing data to CMS for Q3 FY 2024, lacking a policy for Payroll Based Journal submission and resulting in reporting errors.
Report Facts
Residents reviewed: 20
Narcotic vials: 4
PBJ quarter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Confirmed Resident #17 privacy issue and medication reconciliation issues | |
| Director of Nursing (DON) | Confirmed privacy and dignity concerns, medication reconciliation, and staffing data submission issues | |
| Wound Treatment Nurse | Interviewed regarding pressure ulcer care deficiencies for Residents #28 and #209 | |
| MDS Nurse #1 and MDS Nurse #2 | Confirmed lack of care plan for pressure ulcers | |
| Rehabilitation Director | Confirmed pressure ulcer prevention interventions and wound care issues | |
| Certified Nurse Assistants (CNA) #1 and #2 | Observed and interviewed regarding improper catheter care for Resident #57 | |
| Pharmacy Consultant | Confirmed medication reconciliation deficiencies for controlled substances | |
| Administrator | Confirmed medication storage and staffing data submission deficiencies | |
| Therapy Rehab Director | Reported on Resident #209's immobilizer issues and wound care |
Inspection Report — Oct 29, 2024
Life Safety
Date: Oct 29, 2024
Visit Reason
Survey conducted on 10/29/24 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Oct 29, 2024
Life Safety
Date: Oct 29, 2024
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with NFPA 101 and related electrical system requirements.
Findings
The facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B, affecting all 54 residents at the time of the survey.
Deficiencies (1)
K0911 - Electrical Systems - Other. The facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 29, 2024
Date: Oct 29, 2024
Visit Reason
The Mississippi State Department of Health conducted a survey on 10/29/2024 to assess compliance with Life Safety Code requirements, specifically regarding the date of construction and life safety code compliance.
Findings
The facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B, affecting all 54 residents at the time of the survey.
Deficiencies (1)
M1245 - Based on observation and testing, the facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B.
Report Facts
Deficiencies cited: 1
Inspection Report — Sep 26, 2023
Annual Inspection
Date: Sep 26, 2023
Visit Reason
On 09/26/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 08/17/23. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 09/18/23. No deficiencies were cited in this desk review.
Inspection Report — Aug 17, 2023
Annual Inspection
Date: Aug 17, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 08/14/23 through 08/17/23. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F656, F677 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to failure to implement comprehensive care plans for residents requiring oral and nail care, failure to provide adequate personal hygiene to dependent residents, and failure to prevent infection spread due to improper cleaning of multi-use vital sign equipment.
Deficiencies (3)
F0656 - The facility failed to implement comprehensive care plans for two residents requiring oral and nail care, resulting in unmet needs such as long dirty fingernails and poor oral hygiene.
F0677 - The facility failed to provide necessary personal hygiene to dependent residents, evidenced by chapped, peeling lips, long nails with brown substance underneath, and yellow substance on teeth for two residents.
F0880 - The facility failed to prevent the spread of infection by not cleaning multi-resident use vital sign equipment between residents during medication administration.
Report Facts
Deficiencies cited: 3
Inspection Report — Aug 17, 2023
Routine
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to assess compliance with care plan implementation, personal hygiene assistance, and infection prevention and control practices at the nursing home.
Findings
The facility failed to implement comprehensive care plans for residents requiring oral and nail care, failed to provide adequate personal hygiene assistance as evidenced by residents with long nails, dry cracked lips, and yellow substance on teeth, and failed to properly clean multi-resident use vital sign equipment between residents, increasing infection risk.
Deficiencies (3)
F 0656: The facility failed to develop and implement complete care plans for residents #23 and #39, specifically for oral and nail care needs.
F 0677: The facility failed to provide personal hygiene assistance, resulting in chapped peeling lips, long nails with brown substance, and yellow substance on teeth for residents #23 and #39.
F 0880: The facility failed to prevent infection spread by not cleaning multi-resident use vital sign equipment between residents during medication administration.
Report Facts
Residents sampled for ADLs: 18
Survey days observed for infection control: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed deficiencies in care plan implementation, oral and nail care, and infection control practices. | |
| Minimum Data Set (MDS) Nurse | Responsible for developing comprehensive care plans; confirmed care plans were not followed. | |
| Licensed Practical Nurse (LPN) #1 | Observed not cleaning vital sign equipment between residents. | |
| Certified Nursing Assistant (CNA) #1 | Reported on resident #39's dry, cracked lips and oral care practices. | |
| Certified Nurse Aide (CNA) #4 | Confirmed resident #23's long nails and oral hygiene practices. | |
| Licensed Practical Nurse (LPN) #2 | Confirmed resident #23's long nails and oral care practices. | |
| Licensed Practical Nurse (LPN) #1 | Assigned to resident #39 and observed dry, cracked lips. | |
| Certified Nursing Assistant (CNA) #2 | Assigned to resident #39; confirmed oral care omissions. |
Inspection Report — Aug 16, 2023
Life Safety
Date: Aug 16, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility failed to have a properly installed bypass isolation switch for the generator and failed to properly document monthly load testing of the generator. These deficiencies affected all 54 residents at the time of the survey.
Deficiencies (2)
K0911 - The facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B.
K0918 - The facility failed to properly document records of testing the generator annually as directed by NFPA 110 section 8.4.2.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 16, 2023
Date: Aug 16, 2023
Visit Reason
The survey conducted on 08/16/2023 was a Mississippi State Form inspection as indicated by the form footer and header. The Initial Comments do not explicitly state the inspection type such as annual or complaint, so it is classified as 'other'.
Findings
The facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B, affecting all 54 residents at the time of survey.
Deficiencies (1)
M1245 - Based on observation and testing, the facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 16, 2023
Life Safety
Date: Aug 16, 2023
Visit Reason
Survey conducted on 8/16/23 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found to meet all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Aug 24, 2022
Complaint Investigation
Date: Aug 24, 2022
Visit Reason
The State Agency conducted a complaint survey for CI MS #19486, CI MS #19351 and CI MS#19352 on 8/23/22-8/24/22.
Complaint Details
Complaint investigation for CI MS #19486, CI MS #19351 and CI MS#19352 regarding allegations of Neglect and Abuse; complaints were not substantiated and no deficiencies were cited.
Findings
The State Agency did not substantiate the complaints of CI MS #19486, CI MS#19351 and CI#19352 with allegations of Neglect and Abuse. There were no deficiencies cited and the facility was found in compliance with Medicare and Medicaid requirements.
Report Facts
Complaints investigated: 3
Inspection Report — Jun 14, 2022
Life Safety
Date: Jun 14, 2022
Visit Reason
On 6/14/22 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 5/05/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The facility was found to be in compliance with the Life Safety Code based on the desk review and corrective measures provided.
Inspection Report — Jun 8, 2022
Annual Inspection
Date: Jun 8, 2022
Visit Reason
On 06/08/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 04/28/22.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 06/02/22.
Inspection Report — May 5, 2022
Routine
Date: May 5, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
K0341 - The facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10 and NFPA 101 section 9.6, with a trouble signal observed on the fire alarm panel that could not be reset on the day of survey.
Deficiencies (1)
K0341 - The facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10 and NFPA 101 section 9.6, with a trouble signal observed on the fire alarm panel that could not be reset on the day of survey.
Report Facts
Deficiencies cited: 1
Inspection Report — May 5, 2022
Date: May 5, 2022
Visit Reason
The Mississippi State Department of Health conducted a survey on 05/05/2022 to assess compliance with Life Safety Code requirements.
Findings
The facility failed to maintain a complete manual fire alarm system as the fire alarm panel showed a trouble signal for the tamper switch and could not be reset to normal mode until repaired.
Deficiencies (1)
M1245 - The facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 and NFPA 101, affecting all smoke compartments and all 47 residents on the day of survey.
Report Facts
Deficiencies cited: 1
Inspection Report — May 5, 2022
Life Safety
Date: May 5, 2022
Visit Reason
Survey conducted on 05/05/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Apr 28, 2022
Annual Inspection
Date: Apr 28, 2022
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 4/26/22 to 4/28/22. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid regulations for participation.
Findings
Two deficiencies were cited related to inaccurate resident assessments and failure to ensure all staff were fully vaccinated for COVID-19. The facility failed to accurately complete a Minimum Data Set assessment for one resident and did not implement its COVID-19 vaccination policy for three staff members.
Deficiencies (2)
F0641 - Accuracy of Assessments. The facility failed to accurately complete a Minimum Data Set assessment for one of 13 residents reviewed, specifically Resident #50's dialysis status was not correctly indicated on the 4/3/22 assessment.
F0888 - COVID-19 Vaccination of Facility Staff. The facility failed to ensure all staff were fully vaccinated for COVID-19, with three staff members not fully vaccinated by the required date and remaining on the work schedule beyond the deadline.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 28, 2022
Routine
Date: Apr 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments and staff COVID-19 vaccination status.
Findings
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident by not indicating dialysis treatment. Additionally, the facility did not ensure that three staff members were fully vaccinated for COVID-19 by the required deadline, resulting in noncompliance with the facility's vaccination policy.
Deficiencies (2)
F 0641: The facility failed to accurately complete the Minimum Data Set assessment for Resident #50 by not indicating dialysis treatment on the 4/3/22 assessment.
F 0888: The facility failed to ensure three staff members were fully vaccinated for COVID-19 by March 15, 2022, violating the mandatory vaccination policy.
Report Facts
Residents reviewed for MDS accuracy: 13
Staff employed: 43
Unvaccinated staff members: 3
Resident's BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set (MDS) Nurse | Interviewed regarding inaccurate MDS assessment for Resident #50 | |
| Director of Nursing (DON) | Confirmed dialysis omission in MDS and staff vaccination noncompliance | |
| Administrator | Interviewed about staff vaccination status and policy enforcement | |
| Dietary Staff Member #1 (Dietary Manager) | Unvaccinated staff member interviewed about vaccination status and work restrictions | |
| CNA #2 | Unvaccinated staff member interviewed about vaccination status and work restrictions | |
| CNA #1 | Unvaccinated staff member with unsuccessful telephone interview attempt |
Inspection Report — Jan 5, 2022
Routine
Date: Jan 5, 2022
Visit Reason
A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 1/5/2022.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report — Jul 14, 2021
Complaint Investigation
Date: Jul 14, 2021
Visit Reason
The State Agency conducted a complaint survey, MS #17741 at the facility from 7/13/21 to 7/14/21. The complaint involved Dietary Services related to food not being palatable, Quality of Care related to staffing, and Rehab services related to receiving therapy.
Complaint Details
Complaint MS #17741 involved Dietary Services, Quality of Care, and Rehab services; the complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Complaint number: 17741
Inspection Report — Dec 3, 2020
Complaint Investigation
Date: Dec 3, 2020
Visit Reason
The State Agency conducted a complaint survey CI MS #17233, #17156, and #17085 from 12/3/20. The SA substantiated MS #17156 for resident rights and cited M500. The SA did not substantiate MS #17233 and #17085 for resident rights and notification.
Complaint Details
Complaint investigation CI MS #17156 was substantiated for resident rights with deficiencies cited. Complaints CI MS #17233 and #17085 were not substantiated.
Findings
The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm due to failure to notify the resident's representative of a significant change in the resident's status for one of 33 residents with a COVID positive test result.
Deficiencies (1)
M500 - Residents' rights. The facility failed to notify the resident's representative of a significant change in the resident's status related to a positive COVID-19 test result for one resident.
Report Facts
Complaints investigated: 3
Deficiencies cited: 1
Inspection Report — Dec 3, 2020
Date: Dec 3, 2020
Visit Reason
The document does not explicitly state the survey type in the Initial Comments block; therefore, inspection_type is set to 'other'.
Findings
The facility was found to have failed to notify the resident's representative of a significant change in the resident's status for one of 33 residents with a COVID positive test result.
Deficiencies (1)
M500 - The facility failed to notify the resident's representative of a significant change in the resident's status for one of 33 residents with a COVID positive test result.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 3, 2020
Annual Inspection
Date: Dec 3, 2020
Visit Reason
The State Agency conducted an annual recertification survey at the facility on 12/03/2020.
Findings
The facility was cited for failing to notify the resident's representative of a significant change in the resident's status for one of 33 residents with a COVID positive test result.
Deficiencies (1)
F0580 - Notification of Changes. The facility failed to notify the resident's representative of a significant change in the resident's status for one resident with a positive COVID-19 test result.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 3, 2020
Routine
Date: Dec 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/3/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Dec 3, 2020
Routine
Date: Dec 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/3/20. The State Agency (SA) conducted complaint investigations, MS CI #17156, #17085, and #17233, at the facility on 12/3/20.
Complaint Details
Complaint MS CI #17156 was substantiated with deficiencies cited (F0580). Complaints MS CI #17085 and #17233 were not substantiated.
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. The SA substantiated complaint MS CI #17156 and cited F0580; complaints MS CI #17085 and #17233 were not substantiated.
Deficiencies (1)
F0580 - The facility failed to comply with Medicare and Medicaid participation requirements as substantiated in complaint MS CI #17156.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 11, 2020
Routine
Date: Aug 11, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/11/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — May 28, 2020
Routine
Date: May 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/28/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Sep 17, 2019
Annual Inspection
Date: Sep 17, 2019
Visit Reason
The State Survey Agency conducted an annual recertification survey along with complaints MS #16062, MS #16149, and Facility Reported Incident MS #15946 from 9/15/19 to 9/17/19.
Complaint Details
Complaints MS #16062 and MS #16149 and Facility Reported Incident MS #15946 were investigated and not substantiated; no deficiencies were cited related to these complaints.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for deficiencies related to care planning, quality of care, and resident records. No deficiencies were cited related to the complaint investigations.
Deficiencies (3)
F0656 - The facility failed to develop and implement a comprehensive care plan related to communication between hospice nursing and the facility for one of five residents reviewed for hospice, Resident #35.
F0684 - The facility failed to ensure timely communication of hospice nurse visit notes to the facility for one of five residents reviewed for hospice, Resident #35.
F0842 - The facility failed to maintain accurate medical records for one of five residents reviewed for unnecessary medications, Resident #49, by not removing a discontinued medication order for Trazodone from the medical record.
Report Facts
Deficiencies cited: 3
3 CMS Surveys
CMS Survey — Apr 28, 2022
Apr 28, 2022
CMS Survey — Aug 17, 2023
Aug 17, 2023
CMS Survey — Oct 30, 2024
Oct 30, 2024
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