Inspection Reports for
Leakesville Rehabilitation & Nursing Center
1300 Melody Lane, Leakesville, MS, 39451
Back to Facility Profile65 Reports
Inspection Report — Aug 27, 2026
Annual Inspection
Date: Aug 27, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 08/24/2026 through 08/27/2026. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F880, F628, F641, F656, F657, F684, F695, and F947.
Findings
The facility was found not in compliance with multiple deficiencies including infection control, discharge process, accuracy of assessments, care planning, quality of care, respiratory care, and required nurse aide training.
Deficiencies (8)
F0880 - Infection Prevention & Control. The facility failed to implement Enhanced Barrier Precautions by not wearing required PPE, including a gown, during tracheostomy care for Resident #40.
F0628 - Discharge Process. The facility failed to ensure transfer notices included accurate reasons and understandable information for Residents #3 and #56.
F0641 - Accuracy of Assessments. The facility failed to ensure Resident #9's MDS assessment accurately reflected medication use by coding antipsychotic medication during a period when it was discontinued.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop comprehensive person-centered care plans addressing individualized needs for Residents #3, #6, and #9.
F0657 - Care Plan Timing and Revision. The facility failed to revise Resident #9's care plan to remove antipsychotic medication interventions after discontinuation of the medication.
F0684 - Quality of Care. The facility failed to ensure timely follow-up for removal of 23 surgical staples for Resident #1, resulting in staples remaining for more than 30 days after admission.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to perform tracheostomy care using appropriate technique and failed to monitor Resident #40 during nebulizer treatment, leaving the machine running after medication delivery was complete.
F0947 - Required In-Service Training for Nurse Aides. The facility failed to ensure 13 of 36 CNAs received required annual in-service training in resident abuse prevention and dementia management.
Report Facts
Deficiencies cited: 8
Inspection Report — Aug 27, 2026
Annual Inspection
Date: Aug 27, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 08/24/2026 through 08/27/2026. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and cited M1570.
Findings
M1570 - The facility failed to implement Enhanced Barrier Precautions by not wearing required Personal Protective Equipment, including a gown, while providing tracheostomy care for one of four care observations. The Respiratory Therapist did not wear a gown during care despite the resident being on Enhanced Barrier Precautions.
Deficiencies (1)
M1570 - The facility failed to implement Enhanced Barrier Precautions by failing to wear required Personal Protective Equipment, including a gown, while providing tracheostomy care for one of four care observations.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 26, 2026
Life Safety
Date: Aug 26, 2026
Visit Reason
The State Agency conducted a Life Safety Code survey at the facility on 08/26/2026 to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
The facility was found to have a deficiency related to the failure to properly document the annual testing of the emergency generator as required by NFPA 99. No other deficiencies were cited in emergency preparedness.
Deficiencies (1)
K0918 - The facility failed to properly document records of testing the generator annually as required by NFPA 99, with the last documented test performed on 03/06/2025.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 4, 2026
Complaint Investigation
Date: Aug 4, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #3070207) at the facility on 8/4/26. The investigation focused on nursing services, accidents, discharge, neglect, and quality of care/treatment.
Complaint Details
CI MS #3070207 was investigated for nursing services, accidents, discharge, neglect, and quality of care/treatment. The SA determined the facility was in compliance and no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 4, 2026
Complaint Investigation
Date: Aug 4, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #3070207) at the facility on 8/4/26. The investigation covered nursing services, accidents, discharge, neglect, and quality of care/treatment.
Complaint Details
CI MS #3070207 was investigated for nursing services, accidents, discharge, neglect, and quality of care/treatment. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — May 27, 2026
Complaint Investigation
Date: May 27, 2026
Visit Reason
The State Agency conducted one (1) Complaint Investigation (CI MS # 2809590) related to Quality of Care/Treatment, Falsification of Records/Reports, and Resident Abuse.
Complaint Details
CI MS # 2809590 was investigated related to Quality of Care/Treatment, Falsification of Records/Reports, and Resident Abuse. The facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint Investigations: 1
Inspection Report — May 27, 2026
Complaint Investigation
Date: May 27, 2026
Visit Reason
The State Agency conducted one (1) Complaint Investigation (CI MS #2809590) at the facility on 5/27/26 related to Quality of Care/Treatment, Falsification of Records/Reports, and Resident Abuse.
Complaint Details
CI MS #2809590 was investigated related to Quality of Care/Treatment, Falsification of Records/Reports, and Resident Abuse. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations conducted: 1
Inspection Report — Dec 2, 2025
Annual Inspection
Date: Dec 2, 2025
Visit Reason
On 12/02/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 11/18/25. 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 11/25/25. No deficiencies were cited in this document.
Inspection Report — Nov 18, 2025
Annual Inspection
Date: Nov 18, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 09/22/2025 through 09/25/2025. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F558, F637, F700, F812 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies in accommodating resident needs, assessment completion, bedrail safety, food safety, and infection control practices.
Deficiencies (5)
F0558 - Reasonable accommodations needs/preferences. The facility failed to ensure the call light system accommodated the needs of a resident with contracted hands for one of four survey days.
F0637 - Comprehensive assessment after significant change. The facility failed to complete a Significant Change in Status Minimum Data Set assessment following the placement of a percutaneous endoscopic gastrostomy tube for one resident.
F0700 - Bedrails. The facility failed to complete a bedrail assessment and obtain resident consent to ensure safe and appropriate bedrail use for one resident, misclassifying positioning rails as bedrails.
F0812 - Food procurement, store/prepare/serve-sanitary. The facility failed to ensure food items were dated, labeled, stored, and maintained in a sanitary manner, including undated opened items and improperly stored produce and dry goods.
F0880 - Infection prevention & control. The facility failed to ensure infection prevention and control practices were maintained, as evidenced by not discarding isolation gowns that had fallen to the floor and placing contaminated gowns back into the clean supply bin.
Report Facts
Deficiencies cited: 5
Inspection Report — Nov 18, 2025
Annual Inspection
Date: Nov 18, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 09/22/2025 through 09/25/2025. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M500, M815 and M1570.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies in residents' rights accommodations, safe food handling procedures, and infection control practices.
Deficiencies (3)
M500 - Residents' rights were not fully ensured as the facility failed to accommodate the call light needs of a resident with contracted hands for one of four survey days.
M815 - The facility failed to ensure food items were dated, labeled, stored, and maintained in a sanitary manner according to policy and manufacturer instructions for one of four survey days.
M1570 - Infection prevention and control practices were not maintained as isolation gowns that had fallen to the floor were picked up and placed back into the clean supply bin for PPE use.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 18, 2025
Life Safety
Date: Nov 18, 2025
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this survey.
Inspection Report — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI, MS#27638) at the facility on 1/23/2025. The complaint was investigated for Quality of Care/Treatment related to resident over sedated and other, Nursing Services, and Resident Neglect related to pressure sores.
Complaint Details
CI MS#27638 - Complaint investigated for Quality of Care/Treatment, Nursing Services, and Resident Neglect related to pressure sores. The complaint was not substantiated; no deficiencies were cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI MS#27638) at the facility on 1/23/2025. The complaint was investigated for Quality of Care/Treatment related to resident over sedated and other, Nursing Services, and Resident Neglect related to pressure sores.
Complaint Details
Complaint CI MS#27638 investigated Quality of Care/Treatment, Nursing Services, and Resident Neglect related to pressure sores. The complaint was not substantiated; no deficiencies were cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Oct 15, 2024
Complaint Investigation
Date: Oct 15, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #26121 and CI MS #26200) related to pest control and facility cleanliness, and unresolved grievances.
Complaint Details
CI MS #26121 was investigated related to pest control and the facility not kept clean. CI MS #26200 was investigated regarding unresolved grievances. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Oct 15, 2024
Complaint Investigation
Date: Oct 15, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #26121 and MS #26200 at the facility on 10/15/24. MS #26121 was investigated related to pest control and the facility not kept clean. MS #26200 was investigated related to unresolved grievances.
Complaint Details
Complaint Investigations MS #26121 and MS #26200 were conducted; no deficiencies were cited and the facility was found in compliance.
Findings
The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Jul 23, 2024
Follow-Up
Date: Jul 23, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 7/23/24 related to an annual recertification survey that was conducted from 5/6/24 through 5/9/24.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 7/18/24.
Inspection Report — Jul 23, 2024
Follow-Up
Date: Jul 23, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 7/23/24 related to a complaint survey that was conducted from 7/1/24 through 7/2/24.
Complaint Details
Complaint survey conducted from 7/1/24 through 7/2/24; the facility was found in compliance with no deficiencies cited.
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 7/18/24.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 22, 2024
Complaint Investigation
Date: Jul 22, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #25849) related to inappropriate feeding assistance, insufficient foods, and food not palatable.
Complaint Details
CI MS #25849 was investigated related to inappropriate feeding assistance, insufficient foods, and food not palatable. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this investigation.
Report Facts
Complaint investigations: 1
Inspection Report — Jul 22, 2024
Complaint Investigation
Date: Jul 22, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #25849, at the facility on 7/22/24 related to inappropriate feeding assistance, insufficient foods, and food not palatable.
Complaint Details
CI MS#25849 was investigated related to inappropriate feeding assistance, insufficient foods, and food not palatable. The complaint was not substantiated as no deficiencies were cited.
Findings
The surveyor determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited during this investigation.
Inspection Report — Jul 2, 2024
Complaint Investigation
Date: Jul 2, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #25319 and CI MS #25545) at the facility from 7/1/24 through 7/2/24. CI MS #25319 was related to dietary food served cold with no citations, and CI MS #25545 was regarding a resident's right to privacy, resulting in citation F0583.
Complaint Details
Complaint investigation CI MS #25545 was regarding a resident's right to privacy and resulted in citation F0583. CI MS #25319 related to dietary food served cold had no citations.
Findings
The facility was found not in compliance due to a violation of a resident's right to privacy when a resident was visible in a video posted on a staff member's personal social media without consent.
Deficiencies (1)
F0583 - Personal Privacy/Confidentiality of Records. The facility failed to ensure a resident's right to privacy when a video showing Resident #1 was posted on a staff member's personal social media without the resident's consent.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 2, 2024
Complaint Investigation
Date: Jul 2, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #25319 and CI MS #25545) at the facility from 7/1/24 through 7/2/24. CI MS #25319 was related to dietary food served cold with no citations issued. CI MS #25545 was regarding a resident's right to privacy and resulted in a citation.
Complaint Details
CI MS #25545 was investigated regarding a resident's right to privacy and deficiencies were cited. CI MS #25319 related to dietary food served cold was investigated with no citations.
Findings
The facility was found not in compliance with state licensure requirements due to a violation of residents' rights. A resident was visible in a video posted on a staff member's personal social media without her consent, violating privacy rights.
Deficiencies (1)
M500 - The facility failed to ensure a resident's right to privacy as evidenced by a resident who was visible on a video posted to a staff member's personal social media account without her consent.
Report Facts
Complaints investigated: 2
Deficiencies cited: 1
Inspection Report — Jun 21, 2024
Life Safety
Date: Jun 21, 2024
Visit Reason
On 06/21/24 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 05/07/24.
Findings
The facility was found to have corrected the deficient practice and sustained compliance with the 2012 Edition of the Life Safety Code. The State Agency is recommending the facility be placed back in compliance effective 06/21/24.
Inspection Report — Jun 21, 2024
Routine
Date: Jun 21, 2024
Visit Reason
Survey conducted on 05/07/24 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 with no deficiencies cited.
Inspection Report — May 9, 2024
Annual Inspection
Date: May 9, 2024
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI MS #25056) related to verbal abuse and neglect.
Complaint Details
CI MS #25056 related to verbal abuse and neglect was investigated and substantiated with deficiency F0675 cited.
Findings
The facility was found not in compliance during the annual recertification survey with multiple deficiencies cited. The complaint investigation substantiated verbal abuse and neglect with one deficiency cited.
Deficiencies (5)
F0641 - Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set for a resident discharged to home but coded as discharged to another facility.
F0676 - Activities Daily Living (ADLs)/Mntn Abilities. The facility failed to provide a sign language interpreter during clinical appointments for a deaf resident, resulting in missed appointments and unmet communication needs.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to secure a resident in the facility van during transport, resulting in the resident's wheelchair overturning and causing injury risk.
F0802 - Sufficient Dietary Support Personnel. The facility failed to employ sufficient dietary staff to assemble meal trays timely, resulting in late and cold meals for residents.
F0804 - Nutritive Value/Appear, Palatable/Prefer Temp. The facility failed to provide meals at an appetizing temperature, serving cold food to residents.
Report Facts
Deficiencies cited: 7
Inspection Report — May 9, 2024
Annual Inspection
Date: May 9, 2024
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI), MS #25056, at the facility from 05/06/24 through 05/09/24. The SA investigated CI MS #25056 related to verbal abuse and neglect and cited M500 related to the complaint investigation. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and cited M610, M640 and M855.
Complaint Details
Complaint Investigation (CI), MS #25056, related to verbal abuse and neglect. Deficiency M500 was cited related to the complaint investigation.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies related to residents' rights, accident prevention, and food preparation. Issues included failure to provide clean linens, failure to ensure interpreter services for a deaf resident, failure to secure a resident properly during transport, and serving food at unacceptable temperatures.
Deficiencies (3)
M500 - Residents' rights were not ensured as the facility failed to provide clean, blood-free linens for one resident and failed to provide interpreter services for a deaf resident, resulting in missed medical appointments.
M640 - The facility failed to secure a resident properly in the transportation van, resulting in the resident's wheelchair overturning during transport.
M855 - The facility failed to serve resident meals at an appetizing temperature, with residents receiving cold food and complaints about food quality.
Report Facts
Deficiencies cited: 4
Inspection Report — May 7, 2024
Date: May 7, 2024
Visit Reason
The Mississippi State Department of Health conducted a survey on 05/07/2024 to assess compliance with Life Safety Code requirements, specifically reviewing documentation related to fire sprinkler system testing.
Findings
M1245 - The facility failed to properly document quarterly inspections of the fire sprinkler system for three of four quarters in 2023, potentially affecting all 54 residents at the time of survey.
Deficiencies (1)
M1245 - The facility failed to properly document records of quarterly fire sprinkler system inspections for three of four quarters in 2023, which could affect the entire facility.
Report Facts
Deficiencies cited: 1
Inspection Report — May 7, 2024
Life Safety
Date: May 7, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
K0353 - The facility failed to properly document records of quarterly fire sprinkler system inspections for three of four quarters in 2023. This deficiency had the potential to affect all 54 residents at the time of the survey.
Deficiencies (1)
K0353 - The facility failed to properly document records of quarterly fire sprinkler system inspections for three of four quarters in 2023.
Report Facts
Deficiencies cited: 1
Inspection Report — May 7, 2024
Life Safety
Date: May 7, 2024
Visit Reason
Survey conducted on 5/7/24 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 4, 2024
Complaint Investigation
Date: Apr 4, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #24069, MS #24216, MS #24239, and MS #24240, at the facility from 4/3/24 through 4/4/24. MS #24069 was investigated related to accidents and environmental. MS #24216 was investigated regarding administrative license. MS #24239 was investigated related to accidents. MS #24240 was investigated related to resident rights.
Complaint Details
Complaint Investigations MS #24069, MS #24216, MS #24239, and MS #24240 were conducted. The facility was found in compliance and no deficiencies were cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and cited no deficiencies.
Inspection Report — Apr 4, 2024
Complaint Investigation
Date: Apr 4, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CI), MS #24069, MS #24216, MS #24239, and MS #24240, at the facility from 4/3/24 through 4/4/24. MS #24069 was investigated related to accidents and environmental. MS #24216 was investigated regarding administrative license. MS #24239 was investigated related to accidents. MS #24240 was investigated related to resident rights.
Complaint Details
Complaint Investigations MS #24069, MS #24216, MS #24239, and MS #24240 were conducted. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint Investigations: 4
Inspection Report — Apr 10, 2023
Complaint Investigation
Date: Apr 10, 2023
Visit Reason
On 04/10/23 the State Agency conducted a desk review of information related to the complaint survey completed on 02/16/23. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 02/16/23; the desk review confirmed corrective measures and sustained compliance; no deficiencies cited.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 03/31/23. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 10, 2023
Routine
Date: Apr 10, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) from 2/15/23 through 2/16/23.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Mar 20, 2023
Routine
Date: Mar 20, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, potentially causing more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 6, 2023
Routine
Date: Mar 6, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements as specified by CMS and CDC.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 16, 2023
Routine
Date: Feb 16, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and a Complaint Investigation (CI) MS #20373, was conducted by the State Agency (SA) at the facility from 2/15/23 through 2/16/23. The complaint was related to facility Administration, equipment not maintained, services not performed per the plan of care/physician, sufficient supplies, and staff improperly qualified.
Complaint Details
Complaint Investigation (CI) MS #20373 related to facility administration, equipment maintenance, services not performed per plan of care/physician, sufficient supplies, and staff qualifications. Deficiencies were cited.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements and cited for deficiencies related to care plan timing and revision, treatment and services to prevent/heal pressure ulcers, and quality assurance and performance improvement (QAPI) program.
Deficiencies (3)
F0657 - Care Plan Timing and Revision. The facility failed to revise the comprehensive care plan for two of three sampled residents to reflect current physician orders for wound care.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to provide care consistent with professional standards by not completing weekly wound assessments including wound measurements for one pressure injury reviewed.
F0865 - QAPI Program/Plan, Disclosure/Good Faith Attempt. The facility failed to maintain implemented procedures and monitor interventions of the QAPI Committee, indicating an inability to sustain an effective QAPI program.
Report Facts
Deficiencies cited: 3
Inspection Report — Feb 16, 2023
Routine
Date: Feb 16, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 2/15/23 through 2/16/23.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Feb 16, 2023
Complaint Investigation
Date: Feb 16, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #20373, at the facility from 2/15/23 through 2/16/23. The complaint was related to facility Administration, equipment not maintained, services not performed per the plan of care/physician, sufficient supplies, and staff improperly qualified.
Complaint Details
Complaint number CI MS#20373 involved allegations related to facility administration, equipment maintenance, services not performed per plan of care/physician, sufficient supplies, and staff qualifications. Deficiency M615 was cited.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement, and cited M615 for failure to complete weekly wound assessments including wound measurements for one pressure injury.
Deficiencies (1)
M615 - Pressure sores. The facility failed to provide care consistent with professional standards by not completing weekly wound assessments or measuring wounds for one resident with a pressure ulcer.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 3, 2023
Routine
Date: Jan 3, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 27, 2022
Routine
Date: Dec 27, 2022
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a required seven-day period, potentially causing more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 19, 2022
Routine
Date: Dec 19, 2022
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements as part of a routine inspection.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 12, 2022
Routine
Date: Dec 12, 2022
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 12, 2022
Annual Inspection
Date: Dec 12, 2022
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual survey completed on 11/9/22. The information 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 facility was found to be in compliance as the State Agency recommended the facility be placed back in compliance effective 12/2/22.
Inspection Report — Nov 9, 2022
Annual Inspection
Date: Nov 9, 2022
Visit Reason
The State Agency conducted an annual recertification survey along with a Complaint Investigation (CI), MS #19650, at the facility from 11/7/22 through 11/09/22.
Complaint Details
CI MS #19650 was investigated for Abuse and was not substantiated; no deficiencies were cited related to the complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to revise the Comprehensive Care Plan for one resident. The complaint investigation for Abuse was not substantiated and no deficiencies were cited related to the complaint.
Deficiencies (1)
F0657 - Care Plan Timing and Revision. The facility failed to revise the Comprehensive Care Plan for one of 14 sampled residents to include a new physician's order for medication.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 9, 2022
Annual Inspection
Date: Nov 9, 2022
Visit Reason
The State Agency (SA) conducted a recertification survey and a Complaint Investigation (CI), MS #19650, at the facility from 11/07/22 through 11/09/22.
Complaint Details
Complaint Investigation (CI), MS #19650 was not substantiated and there were no deficiencies cited during the survey.
Findings
The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. MS #19650 was not substantiated and there were no deficiencies cited during the survey.
Report Facts
Complaint count: 1
Inspection Report — Nov 7, 2022
Life Safety
Date: Nov 7, 2022
Visit Reason
The facility meets the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
There were no LSC deficiencies cited during this survey. The facility was found in compliance with the Life Safety Code requirements.
Inspection Report — Nov 7, 2022
Routine
Date: Nov 7, 2022
Visit Reason
Survey conducted on 11/07/22 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 — Sep 29, 2022
Complaint Investigation
Date: Sep 29, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #19630 at the facility on 9/29/22.
Complaint Details
Complaint number CI MS#19630 related to staffing and competency in the dietary department was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Sep 29, 2022
Complaint Investigation
Date: Sep 29, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #19630 at the facility on 9/29/22.
Complaint Details
Complaint MS #19630 related to staffing and competency of the dietary department was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited related to staffing and competency of the dietary department.
Report Facts
Complaints investigated: 1
Inspection Report — Sep 14, 2022
Complaint Investigation
Date: Sep 14, 2022
Visit Reason
The State Agency conducted a complaint survey, CI: MS #19397 at the facility on 9/14/22.
Complaint Details
Complaint number CI MS #19397 was investigated for abuse and was not substantiated; no deficiencies were cited.
Findings
The State Agency did not substantiate the complaint for abuse and determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for the Institutions for the Aged or Infirm. There were no deficiencies cited.
Report Facts
Complaints investigated: 1
Inspection Report — Sep 14, 2022
Complaint Investigation
Date: Sep 14, 2022
Visit Reason
The State Agency conducted a complaint survey, CI: MS #19379 at the facility on 9/14/22.
Complaint Details
Complaint number CI MS #19379 was investigated for abuse allegations and was not substantiated; no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited and the complaint for abuse was not substantiated.
Inspection Report — Jul 12, 2022
Complaint Investigation
Date: Jul 12, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19021, MS #19338, and MS #19341, at the facility from 7/11/22 through 7/12/22.
Complaint Details
Complaint Investigation MS #19021, MS #19338, and MS #19341 were not substantiated for misappropriation of property and food issues.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and there were no deficiencies cited.
Inspection Report — Jul 12, 2022
Complaint Investigation
Date: Jul 12, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19021, MS #19338, and MS #19341, at the facility from 7/11/22 through 7/12/22.
Complaint Details
Complaint Investigation MS #19021 and MS #19338 for misappropriation of property were not substantiated. Complaint MS #19341 for food not palatable and resident food preferences not honored was not substantiated.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited.
Report Facts
Complaints investigated: 3
Inspection Report — Apr 4, 2022
Complaint Investigation
Date: Apr 4, 2022
Visit Reason
The State Survey Agency (SSA) conducted a Complaint Investigation (CI) MS #18341 at the facility on 4/4/2022.
Complaint Details
Complaint Investigation (CI) MS #18341 was conducted and found not substantiated; no deficiencies were cited.
Findings
The SSA determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements. The complaint was not substantiated and there were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Apr 4, 2022
Complaint Investigation
Date: Apr 4, 2022
Visit Reason
The State Survey Agency (SSA) conducted a complaint investigation (CI) at the facility on 4/4/2022 for CI # MS 18341 regarding Quality of Care/Treatment involving client not receiving care/services per physician orders, medications not given according to physician instructions and resident left wet for extended periods.
Complaint Details
CI MS 18341 regarding Quality of Care/Treatment involving client not receiving care/services per physician orders, medications not given according to physician instructions and resident left wet for extended periods. The complaint was not substantiated and no deficiencies were cited.
Findings
The SSA determined the facility was in compliance with the requirements of participation in Medicare and Medicaid. The SSA did not substantiate CI #18341 and there were no deficiencies cited.
Inspection Report — Aug 16, 2021
Routine
Date: Aug 16, 2021
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements as specified by CMS and CDC.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. This failure has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 12, 2020
Routine
Date: Oct 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16713, CI MS #16824, CI MS #16848, CI MS #16857, CI MS #16989, CI MS #17025) was conducted by the State Agency (SA) on 10/12/2020.
Complaint Details
The complaint investigations CI MS #16713, #16824, #16848, #16857, #16989, and #17025 were all unsubstantiated with no deficiencies cited for issues including Quality of Care, Resident Neglect, Misappropriation of Property, Client Services, Rehabilitation Services, Admission, Transfer, Discharge, and Resident Abuse.
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. All complaint investigations were unsubstantiated with no deficiencies cited.
Report Facts
Complaint investigations: 6
Inspection Report — Oct 12, 2020
Routine
Date: Oct 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 10/12/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 25, 2020
Complaint Investigation
Date: Jun 25, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 6/25/2020.
Complaint Details
CI MS #16825: Complaint investigation regarding Quality of Care related to Facility Staffing was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited for Quality of Care related to Facility Staffing. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Inspection Report — Jun 19, 2020
Routine
Date: Jun 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/19/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 19, 2020
Routine
Date: Jun 19, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/19/20.
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 — Jun 15, 2020
Routine
Date: Jun 15, 2020
Visit Reason
The facility was surveyed for COVID-19 reporting compliance as required by regulation.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 8, 2020
Routine
Date: Jun 8, 2020
Visit Reason
The survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during the period 06/01/2020 to 06/07/2020 as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 24, 2019
Annual Inspection
Date: Oct 24, 2019
Visit Reason
The State Agency (SA) conducted an annual re-certification survey from 10/22/19 to 10/24/19. The SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F625, F657, and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for failure to provide bed hold policy notifications, failure to revise care plans timely, and failure to prevent infection spread during medication administration.
Deficiencies (3)
F0625 - Notice of bed hold policy before or upon transfer. The facility failed to provide written bed hold policy notification to residents or their representatives at the time of transfer for three of six hospitalizations reviewed.
F0657 - Care plan timing and revision. The facility failed to revise the care plan for Resident #22 to include contact isolation interventions ordered on 10/4/19.
F0880 - Infection prevention and control. The facility failed to prevent possible spread of infection when a nurse placed an uncapped eye drop bottle on a resident's bed linens and then reused it without cleaning the tip.
Report Facts
Deficiencies cited: 3
Inspection Report — Oct 23, 2019
Date: Oct 23, 2019
Visit Reason
Based on the document, the facility was surveyed for compliance with Life Safety Code requirements related to fire drills.
Findings
The facility failed to properly perform fire drills as required by NFPA 101 section 19.7.1.2, missing documentation for fire drills in the 4th quarter of 2018 and the 1st and 2nd quarters of 2019.
Deficiencies (1)
M1245 - The facility failed to properly perform fire drills as required, missing documentation for fire drills in the 4th quarter of 2018 and the 1st and 2nd quarters of 2019.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 9, 2018
Annual Inspection
Date: Nov 9, 2018
Visit Reason
State Survey Agency (SA) conducted an annual recertification survey at the facility from 11/7/18 to 11/9/18. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation.
Findings
The survey identified deficiencies in following physician orders for lab tests, failure to complete gradual dose reductions for psychotropic medications, and infection control issues related to oxygen tubing. The facility was found not in compliance with Medicare and Medicaid requirements.
Deficiencies (3)
F0658 - Services provided did not meet professional standards as the facility failed to follow physician orders for a follow-up Urinalysis with Culture and Sensitivity for Resident #38, resulting in delayed specimen collection and incomplete documentation of refusal.
F0758 - The facility failed to complete a Gradual Dose Reduction for Resident #40's psychotropic medication for depression, despite pharmacy recommendations and regulatory requirements.
F0880 - Infection prevention and control program deficiencies were found as contaminated oxygen tubing was not changed promptly after being found on the floor for Resident #10, posing a risk of infection.
Report Facts
Deficiencies cited: 3
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