37 Reports
Inspection Report — Dec 9, 2025
Annual Inspection
Date: Dec 9, 2025
Visit Reason
On 12/09/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 11/13/25.
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 12/08/25.
Inspection Report — Nov 13, 2025
Annual Inspection
Date: Nov 13, 2025
Visit Reason
The State Agency conducted an annual re-certification survey with one (1) complaint, MS CI #2638073 at the facility from 11/11/25-11/13/25. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation and cited F606, F641, F656, F677, and F688.
Complaint Details
Complaint MS CI #2638073 was investigated during the survey. No deficiencies were cited related to environment, resident rights, and quality of care for this complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies in employment background checks, accuracy of assessments, care planning, ADL care, and mobility services for several residents.
Deficiencies (5)
F0606 - The facility failed to ensure pre-employment background checks were completed prior to allowing newly hired direct care staff to work for two of five employee files reviewed, including CNA #3 and LPN #4.
F0641 - The facility failed to accurately complete a Minimum Data Set assessment related to coding a resident as having a serious mental illness for one of 17 resident MDS assessments reviewed (Resident #3).
F0656 - The facility failed to develop a care plan related to contractures for Resident #25 and failed to implement a care plan related to nail care for Resident #29 for two of 23 sampled resident care plans reviewed.
F0677 - The facility failed to provide ADL care related to fingernail hygiene for one of 56 residents (Resident #29), who was observed with long, dirty fingernails despite scheduled shower days.
F0688 - The facility failed to ensure proper positioning for Resident #14 and failed to provide range of motion services for Resident #25 to prevent further decline in physical functioning for two of three residents reviewed for ROM and positioning.
Report Facts
Deficiencies cited: 5
Inspection Report — Nov 13, 2025
Life Safety
Date: Nov 13, 2025
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this survey.
Inspection Report — Oct 21, 2025
Complaint Investigation
Date: Oct 21, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI #2617592) at the facility on 10/21/25.
Complaint Details
CI #2617592: Complaint investigation conducted; the facility was found in compliance with no deficiencies cited.
Findings
The survey determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid Services.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Apr 10, 2025
Complaint Investigation
Date: Apr 10, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #27665) at the facility on 4/10/25.
Complaint Details
Complaint number CI MS #27665 was investigated and found to be unsubstantiated; no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. There were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Sep 10, 2024
Routine
Date: Sep 10, 2024
Visit Reason
Survey conducted on 07/29/24 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all emergency preparedness requirements; no deficiencies were cited.
Inspection Report — Sep 10, 2024
Follow-Up
Date: Sep 10, 2024
Visit Reason
On 09/10/24 the State Agency (SA) conducted a LSC revisit survey to verify the information that was provided to our agency related to the annual survey that was conducted on 07/29/24.
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 Edition of the Life Safety Code. The SA is recommending that your facility be placed back in compliance effective 08/27/24.
Inspection Report — Sep 3, 2024
Follow-Up
Date: Sep 3, 2024
Visit Reason
The State Agency conducted a revisit to the annual recertification survey on 9/3/24. During the survey, the SA determined the facility was in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm, state licensure requirements as of 8/26/24.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements at the time of the revisit.
Inspection Report — Jul 30, 2024
Annual Inspection
Date: Jul 30, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 7/28/24 through 7/30/24. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and deficiencies were cited at M225, M475, M500, M615, and M625.
Findings
The facility was found not in compliance with state licensure requirements, with deficiencies cited in staffing, employee tuberculosis testing, residents' rights including pain management, pressure sore treatment, and range of motion care. Specific failures included inadequate staffing on weekends, failure to administer second step TB skin tests to employees, failure to provide pain management during wound care, incorrect wound care treatment application, and failure to apply a contracture device leading to decline in range of motion.
Deficiencies (5)
M225 - Staffing. The facility failed to meet the minimum 2.80 hours of direct nursing care per resident per day for seven weekend days reviewed in the second quarter of 2024 due to staff turnover and shortages.
M475 - Employee Testing for Tuberculosis. The facility failed to administer a second step tuberculin skin test to four of five employees reviewed prior to working in the facility.
M500 - Residents' Rights. The facility failed to ensure a resident verbally expressing pain and showing physical nonverbal signs of pain was provided pain management during wound care.
M615 - Pressure Sores. The facility failed to provide wound care treatment as ordered by the physician during wound care for one of three wound care observations, using an incorrect treatment product without notifying the physician.
M625 - Range of Motion. The facility failed to provide services to assure a resident maintained his highest level of range of motion and mobility by not applying a prescribed palm guard to prevent worsening contracture.
Report Facts
Deficiencies cited: 5
Inspection Report — Jul 30, 2024
Annual Inspection
Date: Jul 30, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification at the facility from 7/28/24 through 7/30/24. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F585, F623, F656, F657, F686, F688, F697, and F725.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing eight deficiencies related to grievances, transfer notices, care plans, wound care, mobility, pain management, and staffing.
Deficiencies (8)
F0585 - Grievances. The facility failed to ensure a grievance was documented and resolved for one of four residents present during the resident council meeting, specifically Resident #33 who reported a loose toilet that was not addressed.
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to send written notification to Resident #29 and/or their representative upon transfer to the hospital.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop comprehensive care plans related to pressure ulcer care for Residents #31 and #44 and failed to implement a care plan related to a splinting device for Resident #31.
F0657 - Care Plan Timing and Revision. The facility failed to revise Resident #31's care plan to include a Stage IV pressure ulcer identified on 7/6/24 and to update the care plan related to pain risk.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to provide wound care treatment as ordered by the physician for Resident #44, applying an incorrect dressing without notifying the physician.
F0688 - Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide a contracture device (palm guard) to Resident #31 to maintain range of motion and prevent worsening contractures.
F0697 - Pain Management. The facility failed to provide pain management during wound care for Resident #31 who verbally expressed pain and showed physical signs of pain.
F0725 - Sufficient Nursing Staff. The facility failed to provide sufficient weekend staffing to meet the individualized needs of residents for seven weekend days reviewed in the second quarter of 2024.
Report Facts
Deficiencies cited: 8
Inspection Report — Jul 29, 2024
Life Safety
Date: Jul 29, 2024
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
K0918 - The facility failed to properly maintain the emergency generator, which was found in manual mode and incapable of automatically transferring power within 10 seconds, affecting all residents on the day of survey.
Deficiencies (1)
K0918 - The facility failed to properly maintain the emergency generator, which was in manual mode and unable to automatically transfer power to the facility within 10 seconds, affecting all residents on the day of survey.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 29, 2024
Date: Jul 29, 2024
Visit Reason
The Mississippi State Department of Health conducted a survey on July 29, 2024, to assess compliance with Life Safety Code requirements, specifically focusing on the maintenance of the emergency generator.
Findings
The facility failed to properly maintain the emergency generator, which was found in manual mode and incapable of automatically transferring power within 10 seconds, affecting all residents. Immediate corrective actions were taken, including repair and re-education of staff.
Deficiencies (1)
M1245 - Based on document review, the facility failed to properly maintain the emergency generator as it was in manual mode and could not automatically transfer power within 10 seconds, affecting all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 11, 2024
Life Safety
Date: Jun 11, 2024
Visit Reason
On 06/11/24, a Complaint Investigation (CI MS# 25422) was completed by the Mississippi State Department of Health Bureau of Health Facilities Licensure & Certification: Fire Safety & Construction Division to determine if the facility met the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Complaint Details
Complaint Investigation CI MS# 25422 was conducted to assess compliance with the 2012 Edition of the Life Safety Code; no deficiencies were cited and the facility was found in compliance.
Findings
This survey found the facility to be in compliance with the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), with no deficiencies cited.
Inspection Report — May 30, 2024
Complaint Investigation
Date: May 30, 2024
Visit Reason
The State Agency conducted five complaint investigations (CI MS# 24459, CI MS# 25100, CI MS# 25182, CI MS# 25183, and CI MS# 25189) at the facility from 5/28/24 through 5/29/24.
Complaint Details
Five complaint investigations (CI MS# 24459 related to accidents, CI MS# 25100, CI MS# 25182, CI MS# 25183, and CI MS# 25189 related to abuse) were conducted and no deficiencies were cited; the facility was found in compliance.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. There were no deficiencies cited for any of the complaint investigations.
Report Facts
Complaint investigations conducted: 5
Inspection Report — Apr 30, 2024
Complaint Investigation
Date: Apr 30, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS#24874) regarding allegations of abuse at the facility on 4/30/24.
Complaint Details
Complaint CI MS#24874 alleged abuse at the facility; the complaint was investigated and no deficiencies were cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jan 2, 2024
Complaint Investigation
Date: Jan 2, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #23706) at the facility on 1/2/24.
Complaint Details
Complaint number CI MS #23706 involved an investigation of neglect. The complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. No deficiencies were cited during the investigation of neglect.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 22, 2023
Follow-Up
Date: Jun 22, 2023
Visit Reason
The State Agency conducted a revisit survey on 6/22/23 for the complaint survey on 6/1/23 for CI MS #21624. The SA determined the corrective measures put in place by the facility corrected the deficiencies cited on the 6/22/23 survey.
Complaint Details
CI MS #21624 complaint survey on 6/1/23; the SA determined the facility corrected the deficiencies cited and was in compliance on the revisit.
Findings
The facility was found to have corrected the deficiencies cited in the prior complaint survey. No deficiencies were cited on this revisit survey.
Report Facts
Complaint surveys: 1
Inspection Report — Jun 1, 2023
Complaint Investigation
Date: Jun 1, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI) MS #21624 related to misappropriation of property and pharmaceutical services from 5/31/23 through 6/01/23.
Complaint Details
Complaint Investigation (CI) MS #21624 related to misappropriation of property and pharmaceutical services. Deficiencies were cited related to pharmaceutical services including narcotic reconciliation and secure storage.
Findings
The facility was found not in compliance with pharmaceutical services requirements, citing failures in maintaining accurate controlled drug records and secure storage of narcotics. The investigation revealed missing hydrocodone pills found in a resident's possession and unsecured narcotics in the facility.
Deficiencies (2)
F0755 - The facility failed to maintain a sufficient system of receipt and disposition to accurately reconcile controlled drugs and failed to periodically reconcile controlled drugs for one of two medication carts observed.
F0761 - The facility failed to store controlled drugs locked and in permanently affixed compartments as evidenced by missing hydrocodone pills found in a resident's possession, unsecured narcotics in the Assistant Director of Nursing's office drawer, and Ativan vials stored unsecured in the medication room refrigerator.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 26, 2023
Complaint Investigation
Date: Apr 26, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 21352) at the facility from 4/25/23 through 4/26/23.
Complaint Details
CI MS# 21352 Injury of Unknown Origin. The complaint was investigated and no deficiencies were cited; the facility was found in compliance for this complaint.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services for CI MS# 21352 Injury of Unknown Origin. However, the facility remains out of compliance due to deficiencies cited on the 4/13/2023 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Apr 13, 2023
Annual Inspection
Date: Apr 13, 2023
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 4/10/2023 to 4/13/2023. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in areas including safe environment, physical restraints, PASARR coordination, comprehensive care plans, CPR code status, drug regimen, food safety, and infection control.
Deficiencies (8)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to replace a broken overbed table for one resident, Resident #40, which posed a safety risk.
F0604 - Right to be free from physical restraints. The facility failed to ensure one resident, Resident #26, was free from physical restraints as a full side rail was used without proper consent, physician order, or care plan.
F0644 - Coordination of PASARR and assessments. The facility failed to submit a change in status referral for a Level II resident review for Resident #44 after new mental health diagnoses were made.
F0656 - Develop/implement comprehensive care plan. The facility failed to develop and implement care plans for behavior and side effect monitoring related to psychotropic medications and side rail use for Residents #4, #26, and #44.
F0678 - Cardio-pulmonary resuscitation (CPR). The facility failed to ensure consistent documentation of a resident's code status, with conflicting Full Code and Do Not Resuscitate orders for Resident #18.
F0757 - Drug regimen is free from unnecessary drugs. The facility failed to ensure monitoring for side effects and targeted behaviors related to psychotropic drug use for Residents #4 and #44.
F0812 - Food procurement, store/prepare/serve-sanitary. The facility failed to prevent possible infection spread by storing an ice scoop on the ice inside the ice machine instead of in a proper holder.
F0880 - Infection prevention & control. The facility failed to prevent possible infection spread when a nurse placed gloves in her pocket and then used the contaminated gloves during a finger stick on Resident #1.
Report Facts
Deficiencies cited: 8
Inspection Report — Apr 11, 2023
Life Safety
Date: Apr 11, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to have deficiencies related to exit discharge and fire alarm system installation, affecting the safety of residents and the building's compliance with fire safety codes.
Deficiencies (2)
K0271 - Exit discharge was not properly arranged; one of seven exits failed to release and open upon activation and testing of the fire alarm and sprinkler systems.
K0341 - The facility failed to maintain a complete manual fire alarm system; the fire alarm panel showed a trouble signal and could not be reset, affecting all smoke compartments and 57 residents.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 11, 2023
Annual Inspection
Date: Apr 11, 2023
Visit Reason
The State Agency conducted an annual licensure survey at the facility on 04/11/2023.
Findings
The facility failed to maintain a complete manual fire alarm system as the fire alarm panel showed a trouble signal that could not be reset, affecting all smoke compartments and all 57 residents on the day of the survey.
Deficiencies (1)
M1245 - The facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 and NFPA 101, with a trouble signal on the fire alarm panel that could not be reset, affecting all smoke compartments and all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 12, 2022
Complaint Investigation
Date: Jul 12, 2022
Visit Reason
The State Agency conducted a complaint survey MS #18807 and MS #19325 from 7/11/22-7/12/22. The SA did not substantiate the complaint of MS #18807 with allegations of Abuse/Resident to Resident and MS #18325 with allegations of Sexual Abuse/Resident to Resident.
Complaint Details
Complaint MS #18807 alleged Abuse/Resident to Resident and MS #19325 alleged Sexual Abuse/Resident to Resident. Both complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 14, 2020
Routine
Date: Dec 14, 2020
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network. The facility failed to report complete COVID-19 information to the CDC's NHSN between 12/07/2020 and 12/13/2020 as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 7, 2020
Routine
Date: Dec 7, 2020
Visit Reason
Based on the initial comments, the survey was conducted as a routine COVID-19 focused survey to assess the facility's reporting to the National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 2, 2020
Routine
Date: Nov 2, 2020
Visit Reason
Based on the content and tag F884 related to COVID-19 reporting, this was a routine survey focused on COVID-19 reporting requirements.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Deficiencies (1)
F0884 - The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 11, 2020
Routine
Date: Aug 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/11/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 11, 2020
Routine
Date: Aug 11, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/11/2020.
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 — Jul 20, 2020
Routine
Date: Jul 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/20/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jul 20, 2020
Routine
Date: Jul 20, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 7/20/20.
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 — Jul 13, 2020
Routine
Date: Jul 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/13/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jul 13, 2020
Routine
Date: Jul 13, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 7/13/20.
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 — May 29, 2020
Routine
Date: May 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/29/20.
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 12, 2020
Annual Inspection
Date: Mar 12, 2020
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 03/09/2020 to 03/12/2020. During the survey, the SA determined that the facility was not in compliance with Medicare and Medicaid requirements of participation and cited F656.
Findings
The facility was found not in compliance due to failure to develop and implement a comprehensive care plan addressing the use of an anticoagulant for one resident. Fire drill documentation was incomplete for the previous year, and the facility failed to properly perform fire drills as required. The facility met all emergency preparedness requirements with no deficiencies cited.
Deficiencies (2)
F0656 - The facility failed to develop and implement a comprehensive person-centered care plan addressing the use of an anticoagulant for one resident receiving Eliquis.
K0712 - The facility failed to properly perform and document fire drills as required by NFPA 101, affecting all residents.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 30, 2020
Complaint Investigation
Date: Jan 30, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 1/30/20. The investigation was unsubstantiated with no deficiencies cited.
Complaint Details
CI MS #16384: Complaint investigation conducted and found unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements for participation. No deficiencies were cited.
Inspection Report — Oct 16, 2019
Complaint Investigation
Date: Oct 16, 2019
Visit Reason
The State Agency conducted a complaint survey, MS #16298, on 10/16/19. During the survey, the facility was found not in compliance with Medicare and Medicaid requirements and cited for F600 related to supervision of a resident for sexual abuse behaviors.
Complaint Details
CI MS #16298: The complaint involved allegations of sexual abuse behaviors by a male resident. The complaint was substantiated with deficiencies cited.
Findings
F0600 - The facility failed to prevent a male resident, who was a registered sex offender, from attempting sexual contact with two female residents. Despite a care plan and supervision measures, the facility did not adequately supervise the resident to prevent inappropriate behavior.
Deficiencies (1)
F0600 - The facility failed to prevent a male resident, a registered sex offender, from attempting sexual acts with two female residents due to inadequate supervision and failure to implement effective safeguards.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 23, 2019
Annual Inspection
Date: Feb 23, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 02/21/19 to 02/23/19. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid regulations for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations with deficiencies cited in medication self-administration assessment, transfer/discharge notice requirements, respiratory care, psychotropic medication use, and infection prevention and control.
Deficiencies (6)
F0554 - Resident Self-Admin Meds-Clinically Approp. The facility failed to assess a resident prior to allowing self-administration of a hand-held inhaler for one resident.
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to notify the resident's representative and the Ombudsman in writing of hospital transfers for two residents.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to store oxygen tubing and a nebulizer mask in a manner to prevent contamination for one resident.
F0758 - Free from Unnec Psychotropic Meds/PRN Use. The facility failed to initiate a stop date for psychotropic medications for one resident.
F0880 - Infection Prevention & Control. The facility failed to prevent potential spread of infection as the nurse placed the resident's inhaler and eye drops in her pocket during medication administration for one resident.
K0341 - Fire Alarm System - Installation. The facility failed to maintain a complete manual fire alarm system as the fire alarm panel showed a trouble signal and could not be reset to normal mode.
Report Facts
Deficiencies cited: 6
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