Inspection Reports for
Mississippi Care Center of Alcorn County
3701 Joanne Drive, Corinth, MS, 38834
Back to Facility Profile39 Reports
Inspection Report — Aug 13, 2026
Date: Aug 13, 2026
Visit Reason
On 08/13/26 the State Agency (SA) conducted a desk review of the information that was provided related to the complaint survey completed on 07/22/26-07/23/26. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
Complaint survey completed on 07/22/26-07/23/26. The facility was found to have corrected the deficient practice and sustained compliance. No deficiencies cited.
Findings
The State Agency is recommending the facility be placed back in compliance effective 08/04/26. No deficiencies were cited in this desk review.
Inspection Report — Aug 13, 2026
Complaint Investigation
Date: Aug 13, 2026
Visit Reason
On 08/13/26 the State Agency conducted a desk review of information related to the complaint survey completed on 07/22/26-07/23/26. The facility confirmed corrective measures were in place and recommended to be placed back in compliance effective 08/04/26.
Complaint Details
Complaint survey completed on 07/22/26-07/23/26; the facility was found in compliance and no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements as of 08/04/26. No deficiencies were cited in this desk review.
Report Facts
Complaint survey dates: 07/22/26-07/23/26
Inspection Report — Jul 23, 2026
Complaint Investigation
Date: Jul 23, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #3049401 and CI MS #3029615) at the facility on 7/22/2026 through 7/23/2026. CI MS #3049401 was investigated for insufficient staffing and pest control. MS #3029615 was investigated for transfer and documentation with no deficiencies cited.
Complaint Details
Two complaint investigations were conducted: CI MS #3049401 for insufficient staffing and pest control, with deficiencies cited; and CI MS #3029615 for transfer and documentation, with no deficiencies cited.
Findings
The facility was found not in compliance due to failure to ensure residents were treated with dignity by providing timely responses to call lights for two residents and one room, resulting in prolonged delays and repeated waits for assistance.
Deficiencies (1)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure timely responses to call lights for two residents and one room, causing prolonged delays and repeated waits for toileting and incontinence care assistance.
Report Facts
Deficiencies cited: 1
Inspection Report — May 4, 2026
Complaint Investigation
Date: May 4, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS# 2978095) at the facility on 5/4/26.
Complaint Details
CI MS# 2978095 - Complaint investigation conducted; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 1
Inspection Report — May 4, 2026
Follow-Up
Date: May 4, 2026
Visit Reason
On 5/4/26 the State Agency (SA) conducted an onsite revisit for the annual survey completed on 3/30/26 through 4/1/26. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 4/23/26. No deficiencies were cited during this revisit.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 1, 2026
Annual Inspection
Date: Apr 1, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 3/30/26 through 4/1/26. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F550, F552, F583, F686, F692, F695, F761, F812, F880, and F925.
Findings
The facility was found not in compliance with multiple requirements including resident rights, informed consent for psychotropic medications, privacy, pressure ulcer care, nutrition, respiratory care, medication storage, food safety, infection control, and pest control.
Deficiencies (10)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure privacy for a urinary catheter drainage bag for one resident, compromising dignity.
F0552 - Right to be Informed/Make Treatment Decisions. The facility failed to obtain informed consent prior to initiating psychotropic medications for five residents.
F0583 - Personal Privacy/Confidentiality of Records. The facility failed to ensure privacy during wound care when a window blind was left open, exposing the resident to view.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to maintain interventions to prevent recurrence of a pressure injury due to improper air mattress settings.
F0692 - Nutrition/Hydration Status Maintenance. The facility failed to provide an ordered nutritional supplement due to back order and did not provide an alternative.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to ensure physician-ordered ventilator settings and proper oxygen integration for a resident's Trilogy ventilator.
F0761 - Label/Store Drugs and Biologicals. The facility failed to date insulin pens and vials on the medication cart, risking administration of expired insulin.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to label and date opened food items in refrigerators, risking food safety.
F0880 - Infection Prevention & Control. The facility failed to use enhanced barrier precautions during high-risk care and failed to maintain urinary catheter tubing off the floor for three residents.
F0925 - Maintains Effective Pest Control Program. The facility failed to maintain effective pest control as flies and a cockroach were observed in the kitchen and dietary manager's office.
Report Facts
Deficiencies cited: 10
Inspection Report — Apr 1, 2026
Annual Inspection
Date: Apr 1, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 3/30/26 to 4/1/26. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements.
Findings
The facility was found not in compliance with multiple licensure requirements including residents' rights, pressure sore care, nutrition, special needs, drug labeling, safe food handling, pest control, and infection control. Deficiencies were identified in informed consent for psychotropic medications, dignity and privacy of residents, pressure injury prevention, nutritional supplementation, respiratory care, insulin storage, food labeling and storage, pest control, and infection prevention practices.
Deficiencies (8)
M0500 - Residents' rights. The facility failed to ensure informed consents were obtained before initiation of psychotropic medications for multiple residents and failed to maintain dignity and privacy during care for two residents.
M0615 - Pressure sores. The facility failed to maintain interventions to prevent recurrence of a pressure injury for one resident whose air mattress was improperly set, contributing to wound reopening.
M0645 - Nutrition. The facility failed to provide an ordered nutritional supplement to prevent weight loss for one resident due to back order and lack of alternative supplementation.
M0655 - Special needs. The facility failed to ensure physician-ordered settings and proper oxygen integration for a Trilogy ventilator for one resident, risking respiratory distress.
M0715 - Labeling of drugs. The facility failed to ensure insulins on medication carts were properly dated when opened, risking administration of unsafe medication.
M0815 - Safe food handling procedures. The facility failed to label and store opened food items properly in the kitchen, with multiple items lacking open or use-by dates.
M0970 - Control of insects, rodents, etc. The facility failed to maintain effective pest control in the kitchen, with multiple flies and a cockroach observed in food preparation and storage areas.
M1570 - Infection control. The facility failed to implement an effective infection control program, including failure to use enhanced barrier precautions during high-risk care and failure to maintain urinary catheter tubing off the floor for three residents.
Report Facts
Deficiencies cited: 8
Inspection Report — Mar 31, 2026
Life Safety
Date: Mar 31, 2026
Visit Reason
The survey was a Life Safety Code survey conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to meet all applicable provisions of the 2012 Edition of the Life Safety Code and no deficiencies were cited during this survey.
Inspection Report — Sep 9, 2025
Complaint Investigation
Date: Sep 9, 2025
Visit Reason
The State Agency conducted complaint investigations CI MS #2606174, CI MS #2561835, and CI MS #2563107 at the facility from 9/8/25 through 9/9/25.
Complaint Details
Complaint investigations CI MS #2606174, CI MS #2561835, and CI MS #2563107 were conducted; the facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint investigations: 3
Inspection Report — May 5, 2025
Date: May 5, 2025
Visit Reason
On 05/05/25 the State Agency (SA) conducted a desk review of the information that was provided related to the complaint survey that was completed on 03/17/25.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that the facility be placed back in compliance effective 04/30/25.
Inspection Report — Mar 6, 2025
Complaint Investigation
Date: Mar 6, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28153 and CI MS #28153) from 3/5/25 to 3/6/25. The facility was determined to be in compliance with requirements for Medicare and Medicaid, but non-compliance was cited for failure to provide supervision to prevent elopement.
Complaint Details
CI MS #28153 and CI MS #28156 involved allegations of failure to provide supervision to prevent elopement. The complaint was substantiated with deficiencies cited, including an Immediate Jeopardy that was removed after corrective actions.
Findings
F0689 was cited for failure to provide adequate supervision to prevent Resident #1, a wandering risk, from exiting the facility unnoticed and unsupervised, resulting in elopement. The resident left the facility at 5:09 AM and was found asleep in an employee's car approximately eight miles away. The facility implemented corrective actions and the Immediate Jeopardy was removed prior to the survey.
Deficiencies (1)
F0689 - The facility failed to provide adequate supervision to prevent Resident #1, a wandering risk, from exiting the facility unnoticed and unsupervised, resulting in elopement and placing residents at risk of serious harm.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Mar 3, 2025
Follow-Up
Date: Mar 3, 2025
Visit Reason
On 03/03/25 the State Agency (SA) conducted an onsite revisit for the annual survey and complaint investigation that was completed on 01/30/25. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 02/24/25. No deficiencies were cited during this revisit.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 30, 2025
Annual Inspection
Date: Jan 30, 2025
Visit Reason
The State Agency (SA) conducted an Annual Re-Certification Survey along with one (1) Complaint Investigation (CI MS # 27465), at the facility from 1/28/25 through 1/30/25. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Complaint Details
Complaint Investigation CI MS #27465 cited F600, F609, F656, F697 related to Abuse and Neglect, failure to implement a care plan, failure to notify the SA of an allegation of abuse and failure to monitor pain.
Findings
The survey identified deficiencies related to resident grievances about cold food and lack of hot water, failure to submit PASRR status change for a resident with new mental illness diagnosis, failure to implement pain management care plans and trauma-informed care for residents with PTSD, and failure to ensure proper food temperature monitoring.
Deficiencies (6)
F0565 - Resident/Family Group and Response. The facility failed to act upon and resolve resident grievances regarding cold food and lack of hot water for six residents in the Resident Council meeting.
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to ensure a home-like environment due to cold water temperatures in the 300-hall shower room.
F0644 - Coordination of PASARR and Assessments. The facility failed to submit a status change for a resident with a new mental illness diagnosis to the PASARR program.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement pain management care plan interventions and failed to develop a care plan with individualized interventions to include triggers for PTSD for two residents.
F0699 - Trauma Informed Care. The facility failed to provide trauma care and services for a resident with a diagnosis of PTSD, including failure to assess triggers and provide mental health services.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to ensure food temperatures were completed and documented adequately, including false documentation of food temperatures and serving cold soup to a resident.
Report Facts
Deficiencies cited: 15
Inspection Report — Jan 29, 2025
Life Safety
Date: Jan 29, 2025
Visit Reason
Survey conducted on 1/29/25 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Sep 10, 2024
Complaint Investigation
Date: Sep 10, 2024
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI MS #26161) at the facility on 09/10/24.
Complaint Details
Complaint investigation CI MS #26161 was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The survey determined that the facility was in compliance with the requirements for participation in Medicare and Medicaid Services.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 14, 2023
Annual Inspection
Date: Nov 14, 2023
Visit Reason
On 11/14/23 the State Agency conducted a desk review of the information provided related to the annual survey completed on 09/21/23. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 11/3/23. No deficiencies were cited in this desk review.
Inspection Report — Sep 26, 2023
Life Safety
Date: Sep 26, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
There were no Life Safety Code deficiencies cited during this survey; the facility met the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Sep 21, 2023
Annual Inspection
Date: Sep 21, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 9/18/23 through 9/21/23. During the survey the SA determined that the facility was not in compliance with Medicare and Medicaid requirements of participation and cited F561, F565, F578, F656, F677, F725 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to deficiencies in resident self-determination, grievance resolution, advance directive documentation, care planning, nursing care, staffing, and infection control.
Deficiencies (7)
F0561 - The facility failed to honor a resident's preference to get up and attend morning activities for one of 24 residents sampled.
F0565 - The facility failed to resolve resident grievances as evidenced by recurring complaints about cold food, staffing shortages, delayed call light responses, and housekeeping issues without documented follow-up for five of eight residents present during resident council meetings.
F0578 - The facility failed to provide a resident with the choice for end-of-life care by not verifying code status when the resident became able to express his wishes.
F0656 - The facility failed to develop and implement a care plan related to nail care for one of 24 residents sampled.
F0677 - The facility failed to perform nail care for a resident dependent on staff for one of 24 residents sampled.
F0725 - The facility failed to ensure adequate nursing staff to meet resident needs as evidenced by delayed call light responses, missed care, and insufficient staff to deliver meals timely for nine of 105 residents reviewed.
F0880 - The facility failed to perform medication administration using proper hand hygiene, failed to ensure a multi-use glucometer was properly cleaned and disinfected, and failed to wear masks in the resident halls during a COVID-19 outbreak for two of four survey days.
Report Facts
Deficiencies cited: 7
Inspection Report — Sep 21, 2023
Annual Inspection
Date: Sep 21, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 9/18/23 through 9/21/23. During the survey the SA determined that the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M500, M610 and M1570.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies in residents' rights, activities of daily living, and infection control.
Deficiencies (3)
M500 - Residents' rights. The facility failed to honor a resident's preference to get up and attend morning activities for one of 24 residents sampled.
M610 - Activities of daily living. The facility failed to perform nail care for a resident dependent on staff for one of 24 residents sampled.
M1570 - Infection control. The facility failed to perform medication administration using proper hand hygiene, failed to ensure a multi-use glucometer was properly cleaned and disinfected, and failed to wear masks in the resident halls during a COVID-19 outbreak for two of four survey days.
Report Facts
Deficiencies cited: 3
Inspection Report — Aug 10, 2023
Complaint Investigation
Date: Aug 10, 2023
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI MS #21800) at the facility on 08/10/23.
Complaint Details
Complaint number CI MS #21800 was investigated and found to be unsubstantiated as the facility was in compliance with all requirements.
Findings
The SA determined that the facility was in compliance with the requirements for participation in Medicare and Medicaid Services.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 1, 2023
Routine
Date: Jun 1, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/31/23 to 6/1/23.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Oct 31, 2022
Complaint Investigation
Date: Oct 31, 2022
Visit Reason
On October 31, 2022 the State Agency (SA) conducted an on site complaint investigation MS00018881 for call lights not answered timely and resident not assisted to bed timely.
Complaint Details
Complaint MS00018881 alleged call lights not answered timely and resident not assisted to bed timely. The complaint was not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate MS00018881 and no deficiencies were cited. The SA determined that the facility was in substantial compliance with the standards for participation in Medicare and Medicaid Services.
Report Facts
Deficiencies cited: 0
Inspection Report — May 27, 2022
Date: May 27, 2022
Visit Reason
On 05/27/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 03/31/22.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending your facility be placed back in compliance effective 05/20/22.
Inspection Report — May 27, 2022
Annual Inspection
Date: May 27, 2022
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual survey conducted on 03/31/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found to be in compliance and the State Agency is recommending that the facility be placed back in compliance effective 05/20/22.
Inspection Report — May 4, 2022
Life Safety
Date: May 4, 2022
Visit Reason
On 5/04/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 3/30/22.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC). The SA is recommending that your facility be placed back in compliance effective 04/22/22.
Inspection Report — Mar 31, 2022
Annual Inspection
Date: Mar 31, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 03/28/22 through 03/31/22 along with Complaint Investigations (CI) MS00018373, MS00018327, MS00017878 and MS00017936. During the survey the SA found that the facility was not in compliance with Medicare and Medicaid regulations.
Complaint Details
Complaint Investigations MS00017878, MS00017936, MS00018373, and MS00018327 were not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations. Deficiencies were cited related to a fall from a mechanical lift and infection control practices.
Deficiencies (2)
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to ensure a resident was free from falls during a transfer using a mechanical lift due to improper use of the lift by staff, resulting in the resident sliding through the lift straps and falling to the floor.
F0880 - Infection Prevention & Control. The facility failed to maintain proper placement of a urinary catheter bag and failed to perform medication administration with proper hand hygiene, increasing the risk of infection transmission.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Mar 30, 2022
Routine
Date: Mar 30, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
The facility failed to provide 20-minute fire resistance rating smoke barrier doors that properly close and latch upon activation of the fire alarm and sprinkler systems, affecting all 83 residents. The issue was acknowledged by the Administrator and Maintenance Supervisor and was corrected by 03/29/22 after repairs were made.
Deficiencies (1)
K0374 - The facility failed to provide smoke barrier doors that properly close and latch upon activation of the fire alarm and sprinkler systems, affecting all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 30, 2022
Life Safety
Date: Mar 30, 2022
Visit Reason
Survey conducted on 03/30/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Feb 22, 2021
Routine
Date: Feb 22, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation (CI) MS #17504 was conducted by State Agency (SA) on 02/22/2021.
Complaint Details
Complaint investigation CI MS #17504 was not substantiated for verbal abuse.
Findings
The facility was found to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. CI MS #17504 was not substantiated for verbal abuse.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 22, 2021
Routine
Date: Feb 22, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 02/22/2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Feb 22, 2021
Complaint Investigation
Date: Feb 22, 2021
Visit Reason
The State Agency conducted complaint investigation (CI) MS #17504 on 02/22/2021.
Complaint Details
Complaint investigation CI MS #17504 was not substantiated for verbal abuse.
Findings
The facility was found to be in compliance with the Minimum Standards for the Aged or Infirm. CI MS #17504 was not substantiated for verbal abuse.
Report Facts
Complaint count: 1
Inspection Report — Nov 9, 2020
Complaint Investigation
Date: Nov 9, 2020
Visit Reason
The State Agency (SA) conducted a complaint investigation MS00016968 at facility on 11/09/20.
Complaint Details
Complaint investigation MS00016968 was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid regulations of participation.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Nov 9, 2020
Routine
Date: Nov 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on November 09, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Nov 2, 2020
Routine
Date: Nov 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 11/2/2020. The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with infection control regulations and Medicare and Medicaid participation requirements. No deficiencies were cited.
Inspection Report — Sep 14, 2020
Routine
Date: Sep 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on September 15, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Aug 18, 2020
Routine
Date: Aug 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from August 17 thru August 18, 2020. The facility was found to be not in compliance with 42 CFR §483.80 infection control regulations.
Findings
F0880 - Infection Prevention & Control. The facility failed to follow CDC guidelines for the use of facemasks in a healthcare setting to prevent pathogen transmission in response to COVID-19, as staff were observed wearing cloth masks without a policy for their use, cleaning, or disposal, increasing the risk of infection spread.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to follow CDC guidelines for the use of facemasks in a healthcare setting to prevent pathogen transmission in response to COVID-19, as staff were observed wearing cloth masks without a policy for their use, cleaning, or disposal, increasing the risk of infection spread.
Report Facts
Deficiencies cited: 1
Inspection Report — May 27, 2020
Routine
Date: May 27, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/27/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Mar 11, 2020
Complaint Investigation
Date: Mar 11, 2020
Visit Reason
The State Agency conducted a complaint investigation CI MS# 16579 on 03/10/20 to 03/11/20, related to concerns of physical environment.
Complaint Details
Complaint CI MS# 16579 related to physical environment concerns was investigated and found not substantiated; no deficiencies were cited.
Findings
The concerns were not substantiated and no deficiencies were cited. The facility was found to be in substantial compliance with Medicare and Medicaid requirements.
Report Facts
Complaints investigated: 1
Inspection Report — Jun 20, 2019
Annual Inspection
Date: Jun 20, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 6/17/19 to 6/20/19. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Findings
The survey identified deficiencies in comprehensive care planning, pressure ulcer prevention and treatment, psychotropic medication management, and infection prevention and control. The facility failed to develop and implement a care plan for a bed cradle for Resident #51, did not ensure the bed cradle was used to prevent pressure ulcers, failed to provide stop dates on PRN psychotropic medications for Residents #31 and #51, and failed to follow proper infection control procedures during catheter and incontinent care for Resident #91.
Deficiencies (4)
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop a care plan for the use of a bed cradle to help prevent pressure ulcers for one of 23 residents reviewed, Resident #51.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to ensure a bed cradle was used as a preventive measure for a resident at risk for recurrent skin breakdown for one of six residents reviewed for pressure ulcers, Resident #51.
F0758 - Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to provide a stop date for PRN psychotropic medications ordered for two of six residents reviewed, Resident #31 and Resident #51.
F0880 - Infection Prevention & Control. The facility failed to prevent the likelihood of the spread of infection during catheter and incontinent care for one of eight residents observed for care, Resident #91.
Report Facts
Deficiencies cited: 4
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