Inspection Reports for Memorial Driftwood Nursing Center

MS, 39501

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Inspection Report Plan of Correction Deficiencies: 0 Dec 1, 2025
Visit Reason
The State Agency conducted a desk review of information related to the Licensure survey completed on 2025-11-13 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2025-11-26.
Inspection Report Complaint Investigation Census: 102 Capacity: 151 Deficiencies: 0 Nov 25, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2593793, at the facility from 11/24/25 through 11/25/25. The investigation was for neglect.
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 #2593793 was investigated for neglect and found no deficiencies.
Inspection Report Complaint Investigation Deficiencies: 0 Nov 25, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2593793, at the facility from 11/24/25 through 11/25/25. The investigation was for neglect.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #2593793 was investigated for neglect and found to be unsubstantiated as no deficiencies were cited.
Inspection Report Annual Inspection Census: 30 Deficiencies: 1 Nov 13, 2025
Visit Reason
The State Agency conducted an annual re-licensure survey at the facility from 11/11/2025 to 11/13/2025 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility failed to maintain adequate heating in resident rooms, with temperatures falling below the minimum regulatory guideline of 75°F during a period of extreme cold weather. Six of 30 resident rooms on Unit 1 were observed to be cold, and residents requested additional blankets.
Deficiencies (1)
Description
Facility failed to maintain room temperatures within the required range of 75°F to 80°F, with observed temperatures as low as 67°F and residents reporting cold rooms and requesting extra blankets.
Report Facts
Resident rooms affected: 6 Resident census during inspection: 30 Thermostat temperature readings: 67 Thermostat temperature readings: 69 Thermostat temperature setting: 74 Outside temperature: 52
Employees Mentioned
NameTitleContext
Certified Nursing Aide (CNA #1)Reported residents complained of being cold and provided blankets
AdministratorConfirmed room temperatures were below minimum standard and explained maintenance staff responsibilities
Inspection Report Annual Inspection Census: 115 Capacity: 151 Deficiencies: 3 Oct 31, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/28/24 through 10/31/24 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with participation requirements and cited for deficiencies related to bowel/bladder incontinence and catheter use, food procurement and sanitary food handling, and infection prevention and control practices.
Severity Breakdown
SS=D: 2 SS=F: 1
Deficiencies (3)
DescriptionSeverity
Failure to ensure an indwelling urinary catheter was clinically indicated for one resident (Resident #87) and lack of documentation supporting catheter necessity.SS=D
Failure to ensure food temperatures were tested under sanitary conditions, specifically failure to sanitize the thermometer between food items.SS=F
Failure to use enhanced barrier precautions by not wearing appropriate personal protective equipment during catheter care for one resident (Resident #87).SS=D
Report Facts
Licensed beds: 151 Resident census: 115 Deficiencies cited: 3
Employees Mentioned
NameTitleContext
Licensed Practical Nurse #2LPNInterviewed regarding catheter orders for Resident #87 and lack of diagnosis documentation
Licensed Practical Nurse #1LPNInterviewed confirming Resident #87 did not have catheter on admission and lack of documentation for catheter placement
Director of NursingDONConfirmed lack of sufficient diagnosis for catheter use and expectation for staff documentation and policy adherence
Nurse PractitionerNPAcknowledged catheter issue with Resident #87 and clarified urinary retention does not justify catheter use
Dietary ManagerDMProvided education on thermometer sanitation and observed return demonstration
Registered DietitianRDConfirmed staff training on thermometer sanitation and proper procedures
Certified Nurse Aide #1CNAObserved not wearing gown during catheter care and admitted failure to follow enhanced barrier precautions
Certified Nurse Aide #2CNAObserved not wearing gown during catheter care and admitted failure to follow enhanced barrier precautions
Registered Nurse #1RNExplained enhanced barrier precautions policy and staff expectations
Inspection Report Annual Inspection Deficiencies: 3 Oct 31, 2024
Visit Reason
The State Agency conducted an annual recertification survey at Driftwood Nursing Center from 10/28/24 through 10/31/24 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 standards related to urinary incontinence management, safe food handling procedures, and infection control. Specific deficiencies included failure to ensure clinical indication for indwelling urinary catheter use, improper sanitization of food thermometers, and failure to use appropriate personal protective equipment during catheter care.
Severity Breakdown
Level II: 3
Deficiencies (3)
DescriptionSeverity
Failed to ensure an indwelling urinary catheter was clinically indicated for one resident (Resident #87).Level II
Failed to ensure food temperatures were tested under sanitary conditions; thermometer was wiped on the same towel between food items without sanitizing.Level II
Failed to use enhanced barrier precautions by not wearing appropriate PPE during catheter care for one resident (Resident #87).Level II
Report Facts
Residents observed with catheters: 4 Kitchen observations: 4 Employees observed for catheter care: 4 Physician order date: Sep 23, 2024
Employees Mentioned
NameTitleContext
Licensed Practical Nurse #2LPNEntered catheter orders for Resident #87 without recalling diagnosis.
Licensed Practical Nurse #1LPNConfirmed Resident #87 did not have catheter on admission and no diagnosis was given for catheter.
Director of NursingDONConfirmed lack of sufficient diagnosis for catheter and emphasized documentation expectations.
Nurse PractitionerNPAcknowledged catheter issue and explained nurse contacted on-call doctor.
CookFailed to sanitize thermometer between food items.
Dietary ManagerDMProvided education on thermometer sanitization and observed return demonstrations.
Registered DietitianConfirmed proper sanitization procedures and training expectations.
Certified Nurse Aide #1CNAFailed to wear gown during catheter care despite awareness of Enhanced Barrier Precautions.
Certified Nurse Aide #2CNAFailed to wear gown during catheter care and acknowledged forgetting PPE.
Registered Nurse #1RNExplained expectations for PPE use and availability.
Inspection Report Annual Inspection Deficiencies: 0 Oct 31, 2024
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 10/31/24 to verify the facility's compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming that corrective measures were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 12/08/24.
Inspection Report Annual Inspection Deficiencies: 0 Oct 31, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 10/31/24 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 12/08/24.
Inspection Report Deficiencies: 0 Oct 29, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report Life Safety Deficiencies: 0 Oct 29, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this inspection.
Inspection Report Complaint Investigation Census: 110 Capacity: 151 Deficiencies: 1 Aug 20, 2024
Visit Reason
The State Agency conducted complaint investigations from 8/19/24 through 8/20/24 related to misappropriation of property and other resident care concerns.
Findings
The facility was found to have a past non-compliance deficiency related to misappropriation of a resident's credit card by a Certified Nursing Assistant (CNA). The facility implemented corrective actions including reimbursement to the resident, staff in-service training, and notification of appropriate authorities, resulting in compliance as of 6/29/24.
Complaint Details
Complaint Investigation MS #26039 was related to misappropriation of property. The allegation involved unauthorized use of a resident's credit card by CNA #1. The facility investigated, reimbursed the resident $330.10, and notified law enforcement and other agencies. CNA #1 was arrested. The deficiency was determined to be past non-compliance as of 6/29/24. Another complaint (MS #26149) regarding resident care was investigated with no deficiencies found.
Severity Breakdown
SS=D: 1
Deficiencies (1)
DescriptionSeverity
Facility failed to ensure a resident's right to be free from misappropriation when staff used a resident's credit card without consent.SS=D
Report Facts
Suspicious charges amount: 330.1 Licensed beds: 151 Resident census: 110 Resident BIMS score: 14 CNA employment dates: Hired 4/22/24, terminated 6/21/24, last day worked 6/05/24. Corrective action completion date: Jun 28, 2024
Employees Mentioned
NameTitleContext
CNA #1Certified Nursing AssistantNamed in misappropriation of resident property finding; arrested for unauthorized use of resident's credit card.
RN #1Registered NurseReceived report of suspicious credit card charges and involved in investigation.
AdministratorFacility AdministratorReceived report of suspicious charges, secured credit card, coordinated investigation and notifications.
Detective #1Local Police DetectiveInvestigated misappropriation allegation and confirmed CNA's arrest and evidence.
Director of NursesDirector of Nurses (DON)Provided in-service training on resident rights and abuse prevention after the incident.
Inspection Report Complaint Investigation Deficiencies: 1 Aug 20, 2024
Visit Reason
The State Agency conducted complaint investigations at Driftwood Nursing Center from 8/19/24 through 8/20/24 related to allegations of misappropriation of property and other complaints including resident left wet for extended periods, infection control, resident abuse, and staffing.
Findings
The facility was found to be in compliance with most complaints except for a past non-compliance related to misappropriation of a resident's credit card by a CNA. The facility implemented corrective actions including reimbursement to the resident, staff in-service training, and notification of appropriate agencies. The deficiency was determined to be past non-compliance as of 6/29/24.
Complaint Details
Complaint Investigation MS #26039 was related to misappropriation of property involving Resident #1. The investigation confirmed unauthorized use of the resident's credit card by CNA #1. The facility took corrective actions including reimbursement of $330.10 to the resident, staff training, and notification of the State Agency, Attorney General's Office, and local law enforcement. CNA #1 had voluntarily terminated employment prior to the allegation being made. Other complaints investigated (MS #26149) related to resident care and staffing had no deficiencies.
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Facility failed to ensure a resident's right to be free from misappropriation when facility staff used a resident's credit card without consent or authorization.Level II
Report Facts
Unauthorized charges amount: 330.1 Number of sampled residents: 5 BIMS score: 14 Employment dates of CNA #1: Hired 4/22/24, terminated 6/21/24, last day worked 6/5/24 Date corrective actions completed: 6/28/24
Employees Mentioned
NameTitleContext
CNA #1Certified Nursing AssistantNamed as the staff member who misappropriated Resident #1's credit card
RN #1Registered NurseReceived report of suspicious charges from Resident Representative
Detective #1Local Police Department DetectiveInvestigated the misappropriation and confirmed CNA #1's involvement
AdministratorFacility AdministratorResponded to the allegation, secured credit card, coordinated investigation and staff training
Director of NursesDirector of NursingProvided information on staff in-service training regarding resident rights and abuse prevention
Inspection Report Plan of Correction Deficiencies: 0 Aug 12, 2024
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2024-06-27 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 2024-08-08.
Complaint Details
The visit was related to a complaint survey completed on 2024-06-27. The facility's corrective actions were reviewed and found satisfactory, leading to a recommendation for compliance reinstatement.
Inspection Report Plan of Correction Deficiencies: 0 Aug 12, 2024
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2024-06-27 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 2024-08-08.
Complaint Details
The visit was related to a complaint survey completed on 2024-06-27. The facility was found to be in compliance based on the desk review.
Inspection Report Complaint Investigation Census: 108 Capacity: 151 Deficiencies: 1 Jun 27, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 06/27/2024 related to pressure ulcers and a resident's fall. The investigation related to pressure ulcers found no deficiencies, while the investigation related to the resident's fall resulted in a cited deficiency.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to develop appropriate interventions for a cognitively impaired resident after a fall to prevent recurrence. Specifically, care plan interventions were not suitable for the resident's cognitive impairment, leading to inadequate fall prevention measures.
Complaint Details
Two complaint investigations were conducted: CI MS #25416 related to pressure ulcers with no deficiencies cited, and CI MS #25425 related to a resident's fall which resulted in a cited deficiency F689.
Severity Breakdown
SS=D: 1
Deficiencies (1)
DescriptionSeverity
Failure to develop appropriate interventions for a cognitively impaired resident after a fall to prevent reoccurrence.SS=D
Report Facts
Census: 108 Total licensed capacity: 151 Deficiency completion date: Aug 8, 2024 Plan of correction audit completion date: Jul 3, 2024 Quality Assurance Nurse audit completion date: Jul 10, 2024 Staff in-service completion date: Jul 31, 2024 Plan of correction monitoring period start date: Jul 3, 2024 Plan of correction monitoring period end date: Dec 31, 2024
Employees Mentioned
NameTitleContext
Director of NursingDirector of NursingConfirmed Resident #1's cognitive impairment and inadequacy of care plan interventions
Registered Nurse #1Registered NurseResponsible for developing care plan interventions after resident falls; confirmed interventions were not appropriate for Resident #1
AdministratorAdministratorExplained facility's daily discussion of falls and expectation for appropriate care plan interventions
Inspection Report Complaint Investigation Deficiencies: 1 Jun 27, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 06/27/2024 related to pressure ulcers and a resident's fall. The investigation related to pressure ulcers found no deficiencies, while the investigation related to a resident's fall resulted in a cited deficiency.
Findings
The facility failed to develop appropriate interventions for a cognitively impaired resident after a fall to prevent recurrence. The care plan interventions were not suitable for the resident's cognitive impairment, and the facility was cited for this deficiency.
Complaint Details
Two complaint investigations were conducted: CI MS #25416 related to pressure ulcers with no deficiencies cited, and CI MS #25425 related to a resident's fall resulting in a Level II deficiency citation.
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Failed to develop appropriate interventions for a cognitively impaired resident after a fall to prevent reoccurrence.Level II
Report Facts
Number of complaint investigations: 2 Number of residents sampled: 3 Number of residents with deficiency: 1 Dates of falls: Resident #1 had falls on 05/15/2024 and 05/23/2024 Plan of correction completion date: Plan of correction to be completed by 08/08/2024
Employees Mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding Resident #1's cognitive impairment and care plan interventions
Registered Nurse #1Registered NurseResponsible for developing care plan interventions after resident falls
AdministratorAdministratorInterviewed about facility discussions on falls and expectations for care plan interventions
Inspection Report Plan of Correction Deficiencies: 1 Apr 8, 2024
Visit Reason
The facility was surveyed to assess compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during the required seven-day reporting period from April 1 to April 7, 2024, as mandated by CMS and CDC regulations. This failure had the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.SS=F
Report Facts
Reporting period: 7
Inspection Report Plan of Correction Deficiencies: 1 Jul 17, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 07/10/2023 to 07/16/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Plan of Correction Deficiencies: 1 Jun 12, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 06/05/2023 to 06/11/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Plan of Correction Deficiencies: 0 Apr 20, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-03-02 to verify compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2023-04-05.
Inspection Report Plan of Correction Deficiencies: 0 Apr 20, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-03-02 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2023-04-05.
Report Facts
Annual survey date: Mar 2, 2023 Desk review date: Apr 20, 2023 Compliance effective date: Apr 5, 2023
Inspection Report Annual Inspection Census: 110 Capacity: 151 Deficiencies: 1 Mar 2, 2023
Visit Reason
The State Agency conducted an Annual Recertification Survey at the facility from 2023-02-27 to 2023-03-02 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 Resident Rights requirements, specifically failing to ensure a resident had ready and reasonable access to personal funds on weekends due to limited staff availability. The facility's Resident Personal Funds policy lacked provisions for weekend access to funds.
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Failed to ensure a resident had ready and reasonable access to personal funds on weekends because office staff was not present.Level II
Report Facts
Licensed beds: 151 Resident census: 110 Sampled residents: 24 Resident trust fund access: 0 BIMS score: 12 Personal funds available to Activities Director: 85
Employees Mentioned
NameTitleContext
Administrative AssistantResponsible for residents' personal trust fund accounts and works Monday through Friday
Activities DirectorHas access to $85 to issue personal funds to residents and works one weekend a month
AdministratorUnaware residents lacked weekend access to funds; informed weekend management does not have access to resident fund accounts
Corporate AdministratorConfirmed weekend management does not have access to resident personal fund account information
Inspection Report Annual Inspection Census: 110 Capacity: 151 Deficiencies: 3 Mar 2, 2023
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 2/27/23 through 3/2/23 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with requirements related to protection and management of personal funds, encoding and transmitting resident assessments, and PASARR screening for mental disorder and intellectual disability. Deficiencies were cited for failure to ensure resident access to personal funds on weekends, failure to timely transmit Minimum Data Set (MDS) assessments, and failure to complete a required PASARR Level II screening for one resident.
Severity Breakdown
Level 3 (SS=D): 2 Level 4 (SS=E): 1
Deficiencies (3)
DescriptionSeverity
Failed to ensure a resident had ready and reasonable access to personal funds on weekends due to limited staff availability.Level 3 (SS=D)
Failed to transmit Minimum Data Set (MDS) assessments by their target dates for 19 of 24 residents reviewed.Level 4 (SS=E)
Failed to complete a Pre-Admission Screening and Resident Review (PASRR) Level II for one of three PASRRs reviewed.Level 3 (SS=D)
Report Facts
Licensed beds: 151 Resident census: 110 Residents reviewed for MDS assessments: 24 Residents with late MDS transmissions: 19 PASRRs reviewed: 3 PASRR Level II not completed: 1
Inspection Report Life Safety Deficiencies: 0 Mar 2, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report Deficiencies: 0 Mar 2, 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 Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report Abbreviated Survey Deficiencies: 0 Aug 25, 2022
Visit Reason
The State Agency conducted a COVID-19 Focused Emergency Preparedness Survey at the facility on 08/25/22.
Findings
The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm and no deficiencies were cited.
Inspection Report Abbreviated Survey Census: 118 Capacity: 151 Deficiencies: 0 Aug 25, 2022
Visit Reason
The State Agency conducted a COVID-19 Focused Emergency Preparedness Survey at the facility on 08/25/22 to assess compliance with infection control regulations and recommended practices for COVID-19 preparedness.
Findings
The facility was found to be in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19, with no deficiencies cited.
Inspection Report Abbreviated Survey Deficiencies: 0 Aug 25, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 08/25/22.
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: 107 Capacity: 151 Deficiencies: 0 Nov 16, 2021
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #18013, at the facility on 11/15/21 through 11/16/21.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid. The complaint was not substantiated for residents not turned, no pressure sore prevention, inappropriate wound care, inappropriate feeding assistance, and no weight loss assessment. No deficiencies were cited.
Complaint Details
Complaint MS #18013 was not substantiated for residents not turned, no pressure sore prevention, inappropriate wound care, inappropriate feeding assistance, and no weight loss assessment.
Inspection Report Complaint Investigation Census: 107 Capacity: 151 Deficiencies: 0 Nov 15, 2021
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS # 18013, at the facility on 11/15/21 through 11/16/21.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. MS # 18013 was not substantiated for residents not turned, no pressure sore prevention, inappropriate wound care, inappropriate feeding assistance, and no weight loss assessment. No deficiencies were cited.
Complaint Details
Complaint Investigation MS # 18013 was not substantiated for residents not turned, no pressure sore prevention, inappropriate wound care, inappropriate feeding assistance, and no weight loss assessment.
Report Facts
Census: 107 Total licensed capacity: 151
Inspection Report Plan of Correction Deficiencies: 1 Jun 21, 2021
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a seven-day period between 06/14/2021 and 06/20/2021 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
F 884: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.F 884
Report Facts
Reporting period: 7
Inspection Report Plan of Correction Deficiencies: 1 Jun 14, 2021
Visit Reason
The inspection was conducted to evaluate the facility's 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 NHSN during a seven-day period from 06/07/2021 to 06/13/2021, as required by regulation, potentially causing more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Deficiencies: 1 Jun 7, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period between 05/31/2021 and 06/06/2021, as required by regulation, potentially causing more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Plan of Correction Deficiencies: 1 May 31, 2021
Visit Reason
The inspection was conducted to assess the facility's 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 seven-day period between 05/24/2021 and 05/30/2021, as required by regulation, potentially causing more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Plan of Correction Deficiencies: 1 May 24, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a seven-day period from 05/17/2021 to 05/23/2021 as required by regulation, potentially causing more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Deficiencies: 1 May 17, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 05/10/2021 and 05/16/2021, as required by regulation. This failure to report has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Complaint Investigation Deficiencies: 1 Jan 21, 2021
Visit Reason
The State Agency conducted a COVID survey and Complaint Investigation (CI) CI MS #17341 on 1/21/2021, substantiating the complaint for misappropriation of resident personal property involving Resident #2.
Findings
The facility failed to protect one of five residents reviewed from misappropriation of resident property. Certified Nursing Assistant (CNA) #6 took Resident #2's bank card and withdrew $300 from his account without repayment. The facility reimbursed Resident #2 and terminated CNA #6. Staff were in-serviced on policies regarding resident property and financial transactions.
Complaint Details
The complaint investigation was substantiated for misappropriation of resident personal property. Resident #2 reported CNA #6 took $300 from his bank account using his bank card without repayment. The facility reimbursed the resident and terminated CNA #6. Resident #2 had moderately impaired cognition (BIMS score 11).
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Failed to ensure one resident was protected from misappropriation of resident property involving unauthorized use of bank card and withdrawal of funds.Level II
Report Facts
Amount withdrawn: 300 Bank fees: 5 Withdrawals: 2 Reimbursement amount: 307 BIMS score Resident #2: 11 BIMS score Resident #3: 15
Employees Mentioned
NameTitleContext
CNA #6Certified Nursing AssistantInvolved in misappropriation of Resident #2's bank card and funds.
AdministratorProvided information about the incident and facility actions.
Activity DirectorProvided information about resident education and meetings.
Social ServicesProvided information about resident alerts and education on safeguarding bank cards.
Inspection Report Complaint Investigation Census: 100 Capacity: 151 Deficiencies: 1 Jan 21, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation (CI MS #17341) were conducted due to a self-reported incident involving misappropriation of resident personal property.
Findings
The facility was found compliant with infection control regulations but failed to protect one resident from misappropriation of property when a Certified Nursing Assistant took $300 from Resident #2's bank account without repayment. The resident was reimbursed, and the staff member was terminated.
Complaint Details
The complaint involved misappropriation of resident personal property by CNA #6 who took $300 from Resident #2's bank account without repayment. The facility reimbursed the resident and terminated the CNA. The claim was not substantiated by the investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
DescriptionSeverity
Failed to ensure one resident was protected from misappropriation of resident property involving unauthorized use of bank card and withdrawal of funds.SS=D
Report Facts
Census: 100 Total Capacity: 151 Amount withdrawn: 300 Withdrawal transactions: 2 Bank fees: 5 BIMS score Resident #2: 11 BIMS score Resident #3: 15
Employees Mentioned
NameTitleContext
CNA #6Certified Nursing AssistantNamed in misappropriation of resident property involving unauthorized withdrawal of funds
Inspection Report Routine Deficiencies: 0 Jan 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/21/21 to assess compliance with emergency preparedness regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report Complaint Investigation Deficiencies: 1 Jan 21, 2021
Visit Reason
The State Agency conducted a COVID survey and Complaint Investigation triggered by complaint CI MS #17341 regarding misappropriation of resident personal property.
Findings
The State Agency substantiated the complaint for misappropriation of resident personal property and determined the facility was not in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm, citing regulation 0500 45.17.2 at a Level II severity.
Complaint Details
Complaint Investigation CI MS #17341 was substantiated for misappropriation of resident personal property.
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Misappropriation of resident personal propertyLevel II
Inspection Report Abbreviated Survey Deficiencies: 0 Jan 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/21/21.
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: 100 Capacity: 151 Deficiencies: 1 Jan 21, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation (CI MS #17341) was conducted by the State Agency on 1/21/21 related to misappropriation of resident personal property.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended COVID-19 practices. The complaint of misappropriation of resident personal property was substantiated and a deficiency (F602) was cited.
Complaint Details
The State Agency substantiated the complaint CI MS #17341 for misappropriation of resident personal property.
Deficiencies (1)
Description
Misappropriation of resident personal property
Inspection Report Complaint Investigation Census: 100 Capacity: 151 Deficiencies: 1 Jan 21, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation (CI MS #17341) were conducted by the State Agency on 1/21/21, triggered by allegations of misappropriation of resident personal property.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended COVID-19 practices. The complaint of misappropriation of resident personal property was substantiated and a deficiency (F602) was cited.
Complaint Details
The State Agency substantiated the complaint CI MS #17341 regarding misappropriation of resident personal property.
Deficiencies (1)
Description
Misappropriation of resident personal property
Report Facts
Census: 100 Total licensed capacity: 151
Inspection Report Abbreviated Survey Census: 94 Capacity: 151 Deficiencies: 0 Dec 10, 2020
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey to assess the facility's compliance with infection control regulations and implementation of recommended practices by CMS and CDC to prepare for COVID-19.
Findings
The facility was found in compliance with infection control regulations and had implemented the recommended practices by CMS and CDC to prepare for COVID-19.
Inspection Report Abbreviated Survey Deficiencies: 0 Dec 10, 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 Abbreviated Survey Deficiencies: 0 Oct 5, 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: 90 Capacity: 151 Deficiencies: 0 Oct 5, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey along with a complaint investigation (CI MS #17114) was conducted by the State Agency on 10/5/2020.
Findings
The facility was found to be in compliance with infection control regulations and implemented recommended COVID-19 practices. The complaint investigation was unsubstantiated with no deficiencies cited for Resident Neglect related to Assess Monitor.
Complaint Details
The complaint investigation (CI MS #17114) was unsubstantiated with no deficiencies cited for Resident Neglect related to Assess Monitor.
Report Facts
Census: 90 Total licensed capacity: 151
Inspection Report Complaint Investigation Census: 90 Capacity: 151 Deficiencies: 0 Oct 5, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey along with a complaint investigation (CI MS #17114) was conducted by the State Agency on 10/5/2020.
Findings
The facility was found to be in compliance with infection control regulations and had implemented recommended practices to prepare for COVID-19. The complaint investigation was unsubstantiated with no deficiencies cited for Resident Neglect related to Assess Monitor.
Complaint Details
Complaint investigation CI MS #17114 was unsubstantiated with no deficiencies cited for Resident Neglect related to Assess Monitor.
Inspection Report Abbreviated Survey Deficiencies: 0 Oct 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 10/5/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report Abbreviated Survey Census: 94 Capacity: 151 Deficiencies: 0 Sep 21, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 9/21/20 to assess the facility's 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 infection control regulations and had implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report Routine Census: 94 Capacity: 151 Deficiencies: 0 Sep 21, 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 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report Routine Deficiencies: 0 Aug 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/31/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report Abbreviated Survey Census: 104 Capacity: 151 Deficiencies: 0 Aug 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/3/20 to assess the facility's compliance with infection control regulations related to 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: 104 Capacity: 151 Deficiencies: 0 Aug 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/3/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report Abbreviated Survey Census: 104 Capacity: 151 Deficiencies: 0 Aug 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/3/20 to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report Routine Census: 111 Capacity: 151 Deficiencies: 0 Jul 14, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report Routine Census: 111 Capacity: 151 Deficiencies: 0 Jul 14, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report Routine Census: 116 Capacity: 151 Deficiencies: 0 Jun 23, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report Routine Census: 116 Capacity: 151 Deficiencies: 0 Jun 23, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 116 Total licensed capacity: 151
Inspection Report Complaint Investigation Deficiencies: 0 Feb 14, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 2/14/2020.
Findings
The investigation was unsubstantiated with no deficiencies cited for Quality of Care. 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 for Quality of Care.
Inspection Report Complaint Investigation Census: 118 Capacity: 151 Deficiencies: 0 Jan 14, 2020
Visit Reason
The State Agency conducted a complaint investigation related to quality of care concerns including bathing/odor, skin rash, environmental issues, dirty/rusty equipment, and missing personal items.
Findings
The investigation was unsubstantiated and the facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Complaint Details
Complaint investigation was unsubstantiated for Quality of Care related to bathing/odor, skin rash, environmental issues, dirty/rusty equipment, and missing personal items including snacks and money.
Report Facts
Licensed beds: 151 Census: 118
Inspection Report Annual Inspection Census: 120 Capacity: 151 Deficiencies: 1 Nov 21, 2019
Visit Reason
The State Agency conducted a recertification survey from 11/18/2019 through 11/21/2019 to determine compliance with the Minimum Standards for the Age & Infirm.
Findings
The facility was found to be in compliance with no deficiencies cited during the recertification survey. However, a prior inspection on 11/18/2019 identified a deficiency related to the sprinkler system inspection documentation, which affected all residents. The sprinkler inspection schedule was updated to quarterly with corrective actions planned.
Severity Breakdown
SS=D: 1
Deficiencies (1)
DescriptionSeverity
Facility could not provide documentation for the quarterly inspection of the sprinkler system during the 1st and 3rd quarters of 2019.SS=D
Report Facts
Census: 120 Total Capacity: 151 Deficiency completion date: 2020
Inspection Report Complaint Investigation Census: 124 Capacity: 151 Deficiencies: 0 Sep 23, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation on 9/23/19 regarding allegations of neglect.
Findings
The investigation was substantiated for neglect but no deficiencies were cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Complaint Details
The complaint investigation was substantiated for neglect with no deficiencies cited.
Inspection Report Annual Inspection Census: 131 Capacity: 151 Deficiencies: 5 Jan 16, 2019
Visit Reason
The State Survey Agency conducted an annual recertification survey from 1/13/19 through 1/16/19 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in comprehensive assessment after significant change, care plan timing and revision, bowel/bladder incontinence and catheter care, food procurement and safety, and infection prevention and control.
Severity Breakdown
SS=D: 4 SS=F: 1
Deficiencies (5)
DescriptionSeverity
Failed to complete the comprehensive Minimum Data Set (MDS) for a resident with a significant change and admission to Hospice in a timely manner for Resident #8.SS=D
Failed to revise the comprehensive care plan related to catheter care to include a securing device for the catheter for Resident #4.SS=D
Failed to ensure Resident #4 had a securing device (catheter leg strap) for the catheter tubing, increasing risk of trauma and catheter dislodgement.SS=D
Failed to follow proper safe/sanitation practices to reheat food to the proper serving temperature of at least 165 degrees and prevent contamination by not cleaning the thermometer between food items.SS=F
Failed to prevent cross contamination during catheter care for Resident #74 by using the same gloved hands to pull covers back and begin catheter care without changing gloves.SS=D
Report Facts
Census: 131 Total Capacity: 151 Deficiencies cited: 5 BIMS score: 7 BIMS score: 8
Employees Mentioned
NameTitleContext
CNA #1Certified Nursing AssistantMentioned in catheter care deficiency for Resident #4
RN #2Registered NurseInterviewed regarding MDS and care plan deficiencies
Director of NursingDirector of NursingInterviewed and involved in multiple findings and corrective actions
DSM #2Dietary Staff Member / CookInvolved in food reheating and thermometer use deficiency
DSM #3Dietary Staff Member / Assistant ManagerInvolved in food reheating deficiency
CNA #3Certified Nursing AssistantInvolved in catheter care cross contamination deficiency for Resident #74
RN #3Registered NurseInterviewed regarding catheter care cross contamination
Inspection Report Annual Inspection Census: 131 Capacity: 151 Deficiencies: 2 Jan 16, 2019
Visit Reason
The inspection was an annual recertification survey conducted to assess compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Findings
The facility was found non-compliant with deficiencies related to urinary incontinence catheter care and safe food handling procedures. Specifically, the facility failed to ensure catheter tubing was properly secured for one resident and failed to follow safe food reheating and thermometer sanitation practices.
Severity Breakdown
Level II: 1 Level I: 1
Deficiencies (2)
DescriptionSeverity
Failure to ensure the resident had a securing device (leg strap) for catheter tubing for one resident.Level II
Failure to follow proper safe/sanitation practices to reheat food to the proper serving temperature of at least 165 degrees and to prevent contamination of food by not cleaning the thermometer between checking each food item.Level I
Report Facts
Census: 131 Total licensed capacity: 151 Deficiencies cited: 2 Temperature observed: 130.8 Temperature observed: 149 Temperature observed: 160
Employees Mentioned
NameTitleContext
Certified Nurse Assistant #1CNAObserved not securing catheter tubing and confirmed lack of catheter strap
Registered Nurse #1RNConfirmed facility policy was not followed regarding catheter strap
Director of NursingDONAssessed resident for adverse findings and confirmed staff did not follow policy on catheter strap
Dietary Staff Member #2CookFailed to prevent contamination by placing thermometer handle in food
Dietary Staff Member #3Assistant ManagerReheated ham twice and served at less than 165 degrees
Dietary ManagerCertified Dietary ManagerConducted inservice training and confirmed policy violations
AdministratorConfirmed policy violations related to food reheating and thermometer use

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