Inspection Report Summary
The most recent inspection on December 1, 2025, found the facility in compliance with Minimum Standards of Operation following a desk review. Earlier inspections showed some deficiencies, including failure to maintain adequate heating in resident rooms during extreme cold in November 2025 and issues with catheter use, food handling, and infection control in late 2024. Complaint investigations related to neglect and misappropriation of resident property were mostly unsubstantiated, except for substantiated cases of misappropriation in 2021 and a cited deficiency for fall prevention interventions in 2024. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent compliance suggests improvement after addressing prior deficiencies related mainly to resident care, safety, and reporting practices.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
68% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint Investigation MS #2593793 was investigated for neglect and found no deficiencies.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Investigation MS #2593793 was investigated for neglect and found to be unsubstantiated as no deficiencies were cited.
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.
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 1
Date: 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)
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
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA #1) | Reported residents complained of being cold and provided blankets | |
| Administrator | Confirmed room temperatures were below minimum standard and explained maintenance staff responsibilities |
Inspection Report
Annual Inspection
Census: 115
Capacity: 151
Deficiencies: 3
Date: 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.
Deficiencies (3)
Failure to ensure an indwelling urinary catheter was clinically indicated for one resident (Resident #87) and lack of documentation supporting catheter necessity.
Failure to ensure food temperatures were tested under sanitary conditions, specifically failure to sanitize the thermometer between food items.
Failure to use enhanced barrier precautions by not wearing appropriate personal protective equipment during catheter care for one resident (Resident #87).
Report Facts
Licensed beds: 151
Resident census: 115
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Interviewed regarding catheter orders for Resident #87 and lack of diagnosis documentation |
| Licensed Practical Nurse #1 | LPN | Interviewed confirming Resident #87 did not have catheter on admission and lack of documentation for catheter placement |
| Director of Nursing | DON | Confirmed lack of sufficient diagnosis for catheter use and expectation for staff documentation and policy adherence |
| Nurse Practitioner | NP | Acknowledged catheter issue with Resident #87 and clarified urinary retention does not justify catheter use |
| Dietary Manager | DM | Provided education on thermometer sanitation and observed return demonstration |
| Registered Dietitian | RD | Confirmed staff training on thermometer sanitation and proper procedures |
| Certified Nurse Aide #1 | CNA | Observed not wearing gown during catheter care and admitted failure to follow enhanced barrier precautions |
| Certified Nurse Aide #2 | CNA | Observed not wearing gown during catheter care and admitted failure to follow enhanced barrier precautions |
| Registered Nurse #1 | RN | Explained enhanced barrier precautions policy and staff expectations |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: 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.
Deficiencies (3)
Failed to ensure an indwelling urinary catheter was clinically indicated for one resident (Resident #87).
Failed to ensure food temperatures were tested under sanitary conditions; thermometer was wiped on the same towel between food items without sanitizing.
Failed to use enhanced barrier precautions by not wearing appropriate PPE during catheter care for one resident (Resident #87).
Report Facts
Residents observed with catheters: 4
Kitchen observations: 4
Employees observed for catheter care: 4
Physician order date: Sep 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Entered catheter orders for Resident #87 without recalling diagnosis. |
| Licensed Practical Nurse #1 | LPN | Confirmed Resident #87 did not have catheter on admission and no diagnosis was given for catheter. |
| Director of Nursing | DON | Confirmed lack of sufficient diagnosis for catheter and emphasized documentation expectations. |
| Nurse Practitioner | NP | Acknowledged catheter issue and explained nurse contacted on-call doctor. |
| Cook | Failed to sanitize thermometer between food items. | |
| Dietary Manager | DM | Provided education on thermometer sanitization and observed return demonstrations. |
| Registered Dietitian | Confirmed proper sanitization procedures and training expectations. | |
| Certified Nurse Aide #1 | CNA | Failed to wear gown during catheter care despite awareness of Enhanced Barrier Precautions. |
| Certified Nurse Aide #2 | CNA | Failed to wear gown during catheter care and acknowledged forgetting PPE. |
| Registered Nurse #1 | RN | Explained expectations for PPE use and availability. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
Facility failed to ensure a resident's right to be free from misappropriation when staff used a resident's credit card without consent.
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
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in misappropriation of resident property finding; arrested for unauthorized use of resident's credit card. |
| RN #1 | Registered Nurse | Received report of suspicious credit card charges and involved in investigation. |
| Administrator | Facility Administrator | Received report of suspicious charges, secured credit card, coordinated investigation and notifications. |
| Detective #1 | Local Police Detective | Investigated misappropriation allegation and confirmed CNA's arrest and evidence. |
| Director of Nurses | Director of Nurses (DON) | Provided in-service training on resident rights and abuse prevention after the incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named as the staff member who misappropriated Resident #1's credit card |
| RN #1 | Registered Nurse | Received report of suspicious charges from Resident Representative |
| Detective #1 | Local Police Department Detective | Investigated the misappropriation and confirmed CNA #1's involvement |
| Administrator | Facility Administrator | Responded to the allegation, secured credit card, coordinated investigation and staff training |
| Director of Nurses | Director of Nursing | Provided information on staff in-service training regarding resident rights and abuse prevention |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
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.
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
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.
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.
Inspection Report
Complaint Investigation
Census: 108
Capacity: 151
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to develop appropriate interventions for a cognitively impaired resident after a fall to prevent reoccurrence.
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
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed Resident #1's cognitive impairment and inadequacy of care plan interventions |
| Registered Nurse #1 | Registered Nurse | Responsible for developing care plan interventions after resident falls; confirmed interventions were not appropriate for Resident #1 |
| Administrator | Administrator | Explained facility's daily discussion of falls and expectation for appropriate care plan interventions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failed to develop appropriate interventions for a cognitively impaired resident after a fall to prevent reoccurrence.
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
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #1's cognitive impairment and care plan interventions |
| Registered Nurse #1 | Registered Nurse | Responsible for developing care plan interventions after resident falls |
| Administrator | Administrator | Interviewed about facility discussions on falls and expectations for care plan interventions |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
Deficiencies (1)
Failed to ensure a resident had ready and reasonable access to personal funds on weekends because office staff was not present.
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
| Name | Title | Context |
|---|---|---|
| Administrative Assistant | Responsible for residents' personal trust fund accounts and works Monday through Friday | |
| Activities Director | Has access to $85 to issue personal funds to residents and works one weekend a month | |
| Administrator | Unaware residents lacked weekend access to funds; informed weekend management does not have access to resident fund accounts | |
| Corporate Administrator | Confirmed weekend management does not have access to resident personal fund account information |
Inspection Report
Annual Inspection
Census: 110
Capacity: 151
Deficiencies: 3
Date: 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.
Deficiencies (3)
Failed to ensure a resident had ready and reasonable access to personal funds on weekends due to limited staff availability.
Failed to transmit Minimum Data Set (MDS) assessments by their target dates for 19 of 24 residents reviewed.
Failed to complete a Pre-Admission Screening and Resident Review (PASRR) Level II for one of three PASRRs reviewed.
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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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.
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.
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.
Inspection Report
Complaint Investigation
Census: 107
Capacity: 151
Deficiencies: 0
Date: 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.
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.
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.
Report Facts
Census: 107
Total licensed capacity: 151
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: 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.
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).
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.
Deficiencies (1)
Failed to ensure one resident was protected from misappropriation of resident property involving unauthorized use of bank card and withdrawal of funds.
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
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nursing Assistant | Involved in misappropriation of Resident #2's bank card and funds. |
| Administrator | Provided information about the incident and facility actions. | |
| Activity Director | Provided information about resident education and meetings. | |
| Social Services | Provided information about resident alerts and education on safeguarding bank cards. |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 151
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failed to ensure one resident was protected from misappropriation of resident property involving unauthorized use of bank card and withdrawal of funds.
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
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nursing Assistant | Named in misappropriation of resident property involving unauthorized withdrawal of funds |
Inspection Report
Routine
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint Investigation CI MS #17341 was substantiated for 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.
Deficiencies (1)
Misappropriation of resident personal property
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
The State Agency substantiated the complaint CI MS #17341 for 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.
Deficiencies (1)
Misappropriation of resident personal property
Inspection Report
Complaint Investigation
Census: 100
Capacity: 151
Deficiencies: 1
Date: 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.
Complaint Details
The State Agency substantiated the complaint CI MS #17341 regarding 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.
Deficiencies (1)
Misappropriation of resident personal property
Report Facts
Census: 100
Total licensed capacity: 151
Inspection Report
Abbreviated Survey
Census: 94
Capacity: 151
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Date: 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.
Complaint Details
The complaint investigation (CI MS #17114) was unsubstantiated with no deficiencies cited for Resident Neglect related to Assess Monitor.
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.
Report Facts
Census: 90
Total licensed capacity: 151
Inspection Report
Complaint Investigation
Census: 90
Capacity: 151
Deficiencies: 0
Date: 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.
Complaint Details
Complaint investigation CI MS #17114 was unsubstantiated with no deficiencies cited for Resident Neglect related to Assess Monitor.
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: Feb 14, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 2/14/2020.
Complaint Details
Complaint investigation was unsubstantiated with no deficiencies cited for Quality of Care.
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.
Inspection Report
Complaint Investigation
Census: 118
Capacity: 151
Deficiencies: 0
Date: 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.
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.
Findings
The investigation was unsubstantiated and the facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Report Facts
Licensed beds: 151
Census: 118
Inspection Report
Annual Inspection
Census: 120
Capacity: 151
Deficiencies: 1
Date: 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.
Deficiencies (1)
Facility could not provide documentation for the quarterly inspection of the sprinkler system during the 1st and 3rd quarters of 2019.
Report Facts
Census: 120
Total Capacity: 151
Deficiency completion date: 2020
Inspection Report
Complaint Investigation
Census: 124
Capacity: 151
Deficiencies: 0
Date: Sep 23, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation on 9/23/19 regarding allegations of neglect.
Complaint Details
The complaint investigation was substantiated for neglect with no deficiencies cited.
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.
Inspection Report
Annual Inspection
Census: 131
Capacity: 151
Deficiencies: 5
Date: 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.
Deficiencies (5)
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.
Failed to revise the comprehensive care plan related to catheter care to include a securing device for the catheter for Resident #4.
Failed to ensure Resident #4 had a securing device (catheter leg strap) for the catheter tubing, increasing risk of trauma and catheter dislodgement.
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.
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.
Report Facts
Census: 131
Total Capacity: 151
Deficiencies cited: 5
BIMS score: 7
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Mentioned in catheter care deficiency for Resident #4 |
| RN #2 | Registered Nurse | Interviewed regarding MDS and care plan deficiencies |
| Director of Nursing | Director of Nursing | Interviewed and involved in multiple findings and corrective actions |
| DSM #2 | Dietary Staff Member / Cook | Involved in food reheating and thermometer use deficiency |
| DSM #3 | Dietary Staff Member / Assistant Manager | Involved in food reheating deficiency |
| CNA #3 | Certified Nursing Assistant | Involved in catheter care cross contamination deficiency for Resident #74 |
| RN #3 | Registered Nurse | Interviewed regarding catheter care cross contamination |
Inspection Report
Annual Inspection
Census: 131
Capacity: 151
Deficiencies: 2
Date: 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.
Deficiencies (2)
Failure to ensure the resident had a securing device (leg strap) for catheter tubing for one resident.
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.
Report Facts
Census: 131
Total licensed capacity: 151
Deficiencies cited: 2
Temperature observed: 130.8
Temperature observed: 149
Temperature observed: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | CNA | Observed not securing catheter tubing and confirmed lack of catheter strap |
| Registered Nurse #1 | RN | Confirmed facility policy was not followed regarding catheter strap |
| Director of Nursing | DON | Assessed resident for adverse findings and confirmed staff did not follow policy on catheter strap |
| Dietary Staff Member #2 | Cook | Failed to prevent contamination by placing thermometer handle in food |
| Dietary Staff Member #3 | Assistant Manager | Reheated ham twice and served at less than 165 degrees |
| Dietary Manager | Certified Dietary Manager | Conducted inservice training and confirmed policy violations |
| Administrator | Confirmed policy violations related to food reheating and thermometer use |
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