Inspection Reports for Ocean Springs Health and Rehabilitation Center

The State Agency conducted a Complaint Investigation (MS #2690736) related to quality of care, physical environment, and infection control at the facility.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.

Complaint Investigation MS #2690736 was investigated related to quality of care, physical environment, and infection control. No deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI), MS #2690736, related to quality of care, physical environment, and infection control at the facility.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.

Complaint Investigation MS #2690736 was investigated related to quality of care, physical environment, and infection control. No deficiencies were cited.

The State Agency conducted a follow-up revisit at the facility on 11/18/25 related to an annual and complaint survey conducted from 9/8/25 through 9/11/25.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 10/8/25.

The State Agency conducted a follow-up revisit at the facility on 11/18/25 related to an annual and complaint survey conducted from 9/8/25 through 9/11/25.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 10/8/25.

The State Agency conducted an annual recertification survey and complaint investigations at Ocean Springs Health & Rehabilitation Center from 2025-09-08 through 2025-09-11 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with several licensure requirements including residents' rights, activities of daily living, safe food handling procedures, and infection control. Deficiencies included failure to respect resident dignity and privacy, inadequate assistance with activities of daily living, unsafe food handling practices, and failure to implement proper infection control precautions.

Complaint investigations were conducted for a resident-on-resident incident and misappropriation of funds; no citations were related to these complaints.

The State Agency conducted an annual recertification survey and complaint investigations related to a resident-on-resident incident and misappropriation of funds at the facility from 09/08/2025 through 09/11/2025.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including respect and dignity, self-determination, notice of rights, privacy, abuse prevention, ADL care, nurse staffing information posting, food safety, payroll based journal reporting, QAPI program effectiveness, and infection prevention and control.

The survey included complaint investigations for a resident-on-resident incident and misappropriation of funds. No citations were related to the complaint investigations.

The State Agency conducted a complaint investigation from 2025-02-11 through 2025-02-13 related to an elopement incident where Resident #1 exited the facility unsupervised.

The facility failed to provide adequate supervision and monitoring of a wandering alarm device, resulting in Resident #1 exiting the facility unsupervised for approximately 30 minutes and walking 0.7 miles crossing a four-lane highway. Immediate Jeopardy was identified but removed after corrective actions were implemented.

The complaint investigation was triggered by an elopement incident involving Resident #1 who exited the facility unsupervised on 2025-02-08. Immediate Jeopardy and Substandard Quality of Care were identified but removed after corrective actions were implemented by 2025-02-10.

The State Agency conducted a complaint investigation from 2025-02-11 through 2025-02-13 related to an elopement incident involving Resident #1 who exited the facility unsupervised.

The facility failed to provide adequate supervision and monitoring of a wander guard device for Resident #1, who was at risk for wandering and elopement, resulting in the resident leaving the facility unnoticed and unsupervised for approximately 30 minutes and walking 0.7 miles crossing a four-lane highway. Immediate Jeopardy was identified but later removed after corrective actions.

The complaint investigation was triggered by an elopement incident where Resident #1 exited the facility unsupervised on 2025-02-08. Immediate Jeopardy and Substandard Quality of Care were identified but were removed after corrective actions were implemented by 2025-02-10.

The State Agency conducted a complaint investigation related to neglect and staffing at the facility.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, with no deficiencies cited.

Complaint investigation MS #27532 related to neglect and staffing; no deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI), MS #27532, related to neglect and staffing at the facility.

The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint Investigation MS #27532 was related to neglect and staffing and was found to be unsubstantiated with no deficiencies cited.

The State Agency conducted complaint investigations related to pressure sores, staffing, food palatability, verbal abuse, call bell response, and resident rights at the facility.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint investigations MS #26087 and MS #26816 were conducted. MS #26087 involved pressure sores, staffing, and food palatability. MS #26816 involved verbal abuse, call bell not answered, and resident rights. No deficiencies were found.

The State Agency conducted complaint investigations related to pressure sores, staffing, food palatability, verbal abuse, call bell response, and resident rights.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigations.

Complaint investigations MS #26087 and MS #26816 were conducted. MS #26087 involved pressure sores, staffing, and food quality. MS #26816 involved verbal abuse, call bell response, and resident rights. No deficiencies were found.

The State Agency conducted two complaint investigations regarding Misappropriation of Property, Physical Environment, Physician Services, Resident Abuse, and Safety at the facility.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigations.

Two complaint investigations (CI MS #25262 and CI MS #25915) were conducted. CI MS #25262 involved Misappropriation of Property, Physical Environment, and Physician Services. CI MS #25915 involved Resident Abuse and Safety. Both complaints were investigated with no deficiencies cited.

The State Agency conducted complaint investigations regarding Misappropriation of Property, Physical Environment, Physician Services, Resident Abuse, and Safety at the facility.

The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements; however, there were no citations issued.

Complaint investigations MS #25262 and MS #25915 were conducted. MS #25262 involved Misappropriation of Property, Physical Environment, and Physician Services. MS #25915 involved Resident Abuse and Safety. No citations were issued.

The State Agency conducted a follow-up revisit at the facility from 5/20/24 through 5/21/24 related to an annual recertification survey along with five complaint investigations conducted from 4/15/24 through 4/18/24.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/16/24.

The visit included five complaint investigations conducted from 4/15/24 through 4/18/24; the facility was found in compliance.

The State Agency conducted a follow-up revisit at the facility from 5/20/24 through 5/21/24 related to an annual recertification survey along with five Complaint Investigations conducted from 4/15/24 through 4/18/24.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/16/24.

The visit included investigation of five Complaint Investigations conducted from 4/15/24 through 4/18/24.

The State Agency conducted a follow-up revisit at the facility from 5/20/24 through 5/21/24 related to an annual recertification survey along with five complaint investigations conducted from 4/15/24 through 4/18/24.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/16/24.

The visit included five complaint investigations conducted from 4/15/24 through 4/18/24; the facility was found in compliance.

The State Agency conducted a follow-up revisit at the facility from 5/20/24 through 5/21/24 related to an annual recertification survey along with five complaint investigations conducted from 4/15/24 through 4/18/24.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/16/24.

The State Agency conducted an annual recertification survey and complaint investigations at the facility from 4/15/24 through 4/18/24 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found non-compliant with residents' rights, urinary incontinence care, accident prevention related to substance use disorder, and infection control standards. Deficiencies included failure to provide timely incontinence care resulting in discomfort and skin excoriations, failure to assess and intervene for a resident with substance abuse disorder, and improper infection control practices such as touching medications with bare hands and discarding soiled linens on the floor.

The survey included complaint investigations related to abuse, resident rights, quality of care, resident records, pressure sores, and a facility reported incident related to abuse. No deficiencies were cited related to abuse or resident rights complaints, but deficiencies were cited related to pressure sores and other areas during the annual survey.

The State Agency conducted an annual recertification survey along with five complaint investigations at the facility from 4/15/24 through 4/18/24.

The survey found deficiencies related to resident rights, comprehensive care plans, accident hazards, bowel/bladder incontinence, payroll based journal reporting, quality assurance program, and infection prevention and control. Several residents experienced issues such as delayed incontinence care, lack of care plan updates, and infection control breaches.

The survey included investigations of five complaints related to abuse, resident rights, quality of care, resident records, and pressure sores. No deficiencies were cited related to abuse or resident rights complaints, but deficiencies were cited related to pressure sores.

The State Agency conducted an annual recertification survey and complaint investigations at the facility from 4/15/24 through 4/18/24, including investigations of multiple complaints related to abuse, resident rights, quality of care, resident records, and pressure sores.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, citing deficiencies related to pressure sores and other standards (M500, M620, M640, and M1570). Specifically, a Level II deficiency was cited for failure to ensure a pressure ulcer intervention involving a low air loss mattress was continued after a resident's room change.

The survey included investigations of complaint investigations CI MS #24717 (abuse, resident's rights, quality of care), CI MS #24347 (resident's rights), CI MS #22889 (resident records), and CI MS #24345 (pressure sores). No deficiencies were cited related to abuse, resident rights, quality of care, or resident records complaints. Deficiency was cited related to pressure sores complaint CI MS #24345.

The State Agency conducted an annual recertification survey along with five complaint investigations at the facility from 4/15/24 through 4/18/24 to assess compliance with Medicare and Medicaid participation requirements and investigate specific complaints related to abuse, resident rights, quality of care, and pressure sores.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to comprehensive care plans, treatment and services to prevent and heal pressure ulcers, and other regulatory requirements. Specific failures included lack of care plan interventions for residents with urinary tract infections and substance use disorder, and failure to ensure a low air loss mattress was moved with a resident after a room change.

Five complaint investigations were conducted: CI MS #24717 related to abuse, resident's rights, and quality of care; CI MS #24347 related to resident's rights; CI MS #22889 related to resident records; CI MS #24211 a Facility Reported Incident related to abuse; and CI MS #24345 related to pressure sores. No deficiencies were cited for complaints except for CI MS #24345 which resulted in citations.

The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable emergency preparedness requirements with no deficiencies cited.

The State Agency conducted a Complaint Investigation from 7/24/2023 through 7/26/2023 related to a Facility Reported Incident involving a resident who was found unresponsive and did not receive CPR or notification of a change in condition.

The facility failed to honor a resident's right to receive CPR and emergency services due to misidentification of the resident's code status, resulting in the resident's death. The investigation identified Immediate Jeopardy which was removed after corrective actions were implemented prior to the survey entrance.

The complaint investigation was triggered by a Facility Reported Incident where Resident #1, who had a Full Code status, was found unresponsive and without pulse or respirations. The nurse mistakenly pulled another resident's chart with a DNR order and did not initiate CPR or emergency services. The Responsible Representative was not notified until the following day. Immediate Jeopardy was identified on 7/25/23 and removed on 7/21/23 after corrective actions.

The State Agency conducted a complaint investigation from 7/24/2023 through 7/26/2023 related to a resident found unresponsive who did not receive CPR and notification of a change in condition.

The facility failed to implement baseline care plan interventions related to CPR for Resident #1, who had a Full Code status but was found unresponsive and did not receive CPR due to a nurse pulling the wrong resident's chart with a DNR order. The resident subsequently expired. The facility also failed to notify the resident's family timely. Immediate Jeopardy and Substandard Quality of Care were identified but later removed after corrective actions.

Complaint Investigation MS #22125 was triggered by a Facility Reported Incident involving Resident #1 who was found unresponsive and did not receive CPR or timely family notification. The investigation identified Immediate Jeopardy and Substandard Quality of Care.

The State Agency conducted a desk review of information related to a complaint survey completed on 04/19/23 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 05/13/23.

The visit was complaint-related, reviewing information from a complaint survey completed on 04/19/23. The facility was found to be in compliance and the complaint was effectively resolved.

The State Agency conducted a desk review of information related to a complaint survey completed on 2023-04-19 to verify corrective measures taken by the facility.

The information provided by the facility confirmed that measures were put in place 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 2023-05-13.

The visit was related to a complaint survey completed on 2023-04-19. The review confirmed corrective actions were implemented and compliance was restored.

The State Agency conducted a Complaint Investigation at the facility on 5/9/23 regarding a complaint for neglect.

The investigation found no deficiencies related to the neglect complaint; however, the facility remains out of compliance due to deficiencies cited in a prior complaint survey dated 4/19/23.

Complaint Investigation MS #21357 for neglect; no deficiencies cited during this investigation.

The State Agency conducted a Complaint Investigation (CI), MS #21357, at the facility on 5/9/23 for resident neglect.

No deficiencies were cited related to the complaint investigation; however, the facility remains out of compliance due to deficiencies cited on the 4/19/23 survey.

Complaint Investigation MS #21357 for resident neglect was conducted and found no deficiencies.

The State Agency conducted complaint investigations at the facility for three complaints from 4/17/23 through 4/19/23, specifically investigating verbal abuse and issues related to water offering, resident assessment, and medication administration.

The facility was found not in compliance with state licensure requirements related to verbal abuse for one of four sampled residents. The investigation revealed a verbal altercation and physical struggle involving Resident #1 and a Certified Nurse Aide (CNA #1), resulting in the CNA's suspension and termination. No deficiencies were cited related to the other complaints.

The complaint investigation involved three complaints (CI MS #20710, CI MS #20797, and CI MS #21326). The facility was found non-compliant related to CI MS #20797 for verbal abuse involving Resident #1 and CNA #1. The CNA was suspended immediately on 2/18/23 and terminated on 2/24/23. Resident #1 was evaluated by a Psychiatric Nurse Practitioner with no adverse findings. The Director of Nursing and other staff conducted interviews and implemented in-service training on abuse prevention.

The State Agency conducted a complaint investigation at the facility for three complaints from 4/17/23 through 4/19/23, including allegations of verbal abuse, water not being offered, resident assessment, and medication administration per physician orders.

The facility was found not in compliance due to verbal abuse involving one resident and a certified nurse aide. The investigation found that the resident and staff member engaged in a verbal altercation and physical struggle over the resident's cane. The CNA was suspended and subsequently terminated. No deficiencies were cited related to other complaints.

The complaint investigation involved three complaints: MS #20710 for verbal abuse, MS #21326 for water not being offered, resident assessment, and medications given per physician orders, and MS #20797 for verbal abuse. No deficiencies were cited for MS #20710 and MS #21326. The facility was cited for verbal abuse under MS #20797. The CNA involved was suspended on 2/18/23 and terminated on 2/24/23. The Director of Nursing and other staff conducted interviews and follow-up actions including resident interviews and staff in-service training.

The State Agency conducted a Complaint Investigation at the facility from 12/02/22 through 12/05/22 regarding multiple complaint survey numbers MS #19577, MS #19624, and MS #19939.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. None of the complaints were substantiated and no deficiencies were cited.

MS #19577 was not substantiated for physical environment and falls. MS #19624 was not substantiated for resident falls, facility staffing, and residents not turned/repositioned timely. MS #19939 was not substantiated for resident grooming, incontinence care, call lights not answered timely, hydration, neglect, resident falls, misappropriation, and resident restraints/seclusion.

The State Agency conducted a complaint investigation at the facility from 12/02/22 through 12/05/22 related to multiple complaint numbers regarding physical environment, falls, facility staffing, resident care, and other concerns.

The facility was found to be in compliance with Medicare and Medicaid requirements. None of the complaints were substantiated and no deficiencies were cited.

The complaints investigated included MS #19577, MS #19624, and MS #19939. None were substantiated for issues including physical environment, falls, staffing, resident care, neglect, misappropriation, and restraints/seclusion.

The State Agency conducted a complaint investigation at Ocean Springs Health & Rehabilitation Center from 08/10/22 through 08/11/22 due to allegations including medication diversion and other complaints.

The investigation substantiated a medication diversion involving a missing card of Percocet 5/325 mg tablets for Resident #1. The facility failed to protect the resident from misappropriation of medication by an LPN who subtracted a medication card with no valid prescription and failed to provide a satisfactory explanation. The facility took corrective actions including terminating the involved LPN, notifying authorities, conducting audits, and providing staff training.

Complaint Investigation MS #19429 was substantiated for medication diversion involving LPN #2 who subtracted a medication card for Resident #1 without authorization. MS #19448 was not substantiated for neglect, pressure sores, infection control, nursing services, and care not received per Physician's Orders.

The State Agency conducted a COVID-19 Focused Infection Control survey and Complaint Investigation at the facility from 08/10/22 through 08/11/22, triggered by complaints MS #19429 and MS #19448.

The facility was found compliant with infection control regulations and CDC/CMS COVID-19 practices. Complaint MS #19448 was not substantiated, but MS #19429 was substantiated for medication diversion involving misappropriation of a resident's medication by a licensed practical nurse (LPN #2). The facility took corrective actions prior to the survey, and the deficiency was cited as past noncompliance.

Complaint MS #19429 was substantiated for medication diversion involving misappropriation of a resident's medication. Complaint MS #19448 was not substantiated for neglect, pressure sores, infection control, nursing services, and care not received per Physician's Orders.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 08/10/22 through 08/11/22.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

The State Agency conducted a Complaint Investigation at the facility from 08/10/22 through 08/11/22 related to allegations identified as MS #19429 and MS #19448.

The investigation found the facility was not in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. MS #19448 was not substantiated for neglect, pressure sores, infection control, nursing services, and care not received per Physician's Orders. MS #19429 was substantiated for a medication diversion and M500 was cited.

MS #19448 was not substantiated for neglect, pressure sores, infection control, nursing services, and care not received per Physician's Orders. MS #19429 was substantiated for a medication diversion.

The State Agency conducted a COVID-19 Focused Infection Control survey and Complaint Investigation at the facility from 08/10/22 through 08/11/22.

The facility was found to be in compliance with infection control regulations and CDC recommended practices for COVID-19, with no deficiencies cited related to infection control. However, the facility was not in compliance with Medicare and Medicaid participation requirements due to substantiated medication diversion.

Complaint Investigation MS #19448 was not substantiated for neglect, pressure sores, infection control, nursing services, and care not received per Physician's Orders. Complaint Investigation MS #19429 was substantiated for medication diversion and F602 was cited.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 08/10/22 through 08/11/22.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

The State Agency conducted a complaint investigation at the facility on 6/17/22 regarding an allegation of sexual abuse.

The complaint for sexual abuse was not substantiated and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited in a prior survey on 4/29/2022.

Complaint investigation (CI MS #18804) for sexual abuse was not substantiated.

The State Agency conducted a Complaint Investigation at the facility on 6/17/22 in response to complaint MS #18804.

The survey did not substantiate the complaint; however, the facility remains out of compliance due to deficiencies cited on the prior 4/29/2022 survey.

Complaint MS #18804 was investigated and found not substantiated.

The facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider to assess compliance with the Life Safety Code (LSC).

The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). There were no LSC deficiencies cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements during the survey.

The State Agency conducted an annual recertification along with six complaint investigations at the facility from 4/25/22 to 4/29/22 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with resident rights, activities of daily living, and pressure sore care standards. Deficiencies included failure to maintain resident dignity during care, unresolved resident grievance regarding personal property, inadequate assistance with bathing, shaving, and nail care for dependent residents, and improper wound care techniques for two residents.

Six complaint investigations were conducted: MS #18410, MS #18423, MS #18499, MS #18631, MS #18736, and MS #18767. The agency substantiated MS #18410 for not providing nail care and MS #18631 for medications not given according to physician's orders and wound care not provided according to professional standards. Other complaints were not substantiated.

The State Agency conducted an annual recertification along with six complaint investigations at the facility from 4/25/22 to 4/29/22 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple regulatory requirements including ADL care, wound care, and medication administration. Several complaints were substantiated related to inadequate nail care, medication errors, and wound care deficiencies. The facility was cited for multiple deficiencies including F550, F585, F608, F610, F677, F686, F760, and F812.

Six complaint investigations were conducted: MS #18410, MS #18423, MS #18499, MS #18631, MS #18736, and MS #18767. The agency substantiated MS #18410 for not providing nail care, MS #18631 for medications not given according to physician's orders and wound care not provided according to professional standards. Other complaints were not substantiated.

The State Agency conducted an annual recertification along with six complaint investigations at the facility from 4/25/22 to 4/29/22 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with several standards including residents' rights, activities of daily living, pressure sore care, and safe food handling procedures. Deficiencies were cited related to dignity during care, unresolved resident grievances, inadequate assistance with bathing and grooming, improper wound care, and food safety violations.

Six complaint investigations were conducted: MS #18410, MS #18423, MS #18499, MS #18631, MS #18736, and MS #18767. The agency substantiated MS #18410 for not providing nail care and MS #18631 for medications not given according to physician's orders and wound care not provided according to professional standards. Other complaints were not substantiated.

The State Agency conducted an annual recertification along with six complaint investigations at the facility from 4/25/22 to 4/29/22 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with several standards including residents' rights, activities of daily living, pressure sore care, and safe food handling procedures. Deficiencies were cited related to dignity in care, unresolved grievances, inadequate bathing and nail care, improper wound care techniques, and failure to properly handle and store food items.

Six complaint investigations were conducted: MS #18410, MS #18423, MS #18499, MS #18631, MS #18736, and MS #18767. The agency substantiated MS #18410 for not providing nail care and MS #18631 for medications not given according to physician's orders and wound care not provided according to professional standards. Other complaints were not substantiated.

The State Agency conducted an annual recertification along with six complaint investigations at the facility from 4/25/22 to 4/29/22 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with several requirements including resident rights, grievance resolution, abuse investigation, ADL care, wound care, medication administration, and food safety. Specific deficiencies included failure to maintain resident dignity during care, unresolved grievances, improper wound care techniques, missed showers and nail care, medication errors related to insulin sliding scale, and expired food items in the kitchen.

The survey included six complaint investigations (MS #18410, MS #18423, MS #18499, MS #18631, MS #18736, MS #18767). Some complaints were substantiated including failure to provide nail care and medication/wound care per orders. Others were not substantiated.

The State Agency conducted a complaint survey from 11/17/21 through 11/18/21 to investigate allegations related to misappropriation of property, abuse, falls, safety/falls, and failure to notify the responsible party of a fall or change of condition.

The survey determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. There were no deficiencies cited and all complaints were not substantiated.

Complaint survey MS #18288 was not substantiated for misappropriation of property or abuse. MS #18114 was not substantiated for falls. MS #18087 was not substantiated for safety/falls or failure to notify the responsible party of fall (change of condition).

The State Agency conducted a complaint survey based on MS #18288, MS #18114, and MS #18087 at the facility from 11/17/21 through 11/18/21.

The facility was found to be in compliance with regulations for participation in CMS. None of the complaints were substantiated and no deficiencies were cited.

MS #18288 was not substantiated for misappropriation of property or abuse. MS #18114 was not substantiated for falls. MS #18087 was not substantiated for safety/falls or failure to notify the responsible party of fall (change of condition).

The State Agency conducted three complaint investigations from 6/7/21 through 6/10/21, including a substantiated complaint related to elopement when the facility failed to provide adequate staff supervision to prevent Resident #3's elopement on 5/22/21.

The facility failed to provide adequate supervision to prevent Resident #3, identified as a wanderer, from eloping and leaving the facility unnoticed and unsupervised for approximately 92 minutes, placing the resident and others at risk of serious injury or death. Immediate Jeopardy was identified but removed prior to the survey entrance after corrective actions were implemented.

Complaint Investigation MS #17826 was substantiated related to elopement. Complaints MS #17819 and MS #17827 related to abuse were unsubstantiated.

The State Agency conducted three complaint investigations from 6/7/21 through 6/10/21, including a substantiated complaint related to elopement when the facility failed to provide adequate staff supervision to prevent Resident #3's elopement on 5/22/21.

The facility failed to provide adequate supervision to prevent Resident #3, identified as an elopement and wander risk, from leaving the facility unnoticed and unsupervised, resulting in an Immediate Jeopardy and Substandard Quality of Care. The resident was found in a parked vehicle one street over from the facility. The facility implemented corrective actions and the Immediate Jeopardy was removed on 5/24/21 prior to the survey entrance.

The complaint investigation CI MS #17826 was substantiated related to elopement. CI MS #17819 and CI MS #17827 were unsubstantiated related to abuse.

The State Survey Agency conducted a complaint investigation based on multiple complaint investigations (CI MS #17662, CI MS #17667, CI MS #17674, CI MS #17675) on 3/29/21.

The investigations were unsubstantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.

Four complaint investigations were conducted (CI MS #17662, CI MS #17667, CI MS #17674, CI MS #17675). All were unsubstantiated with no deficiencies cited related to quality of care or resident neglect.

The inspection was conducted as a complaint investigation for multiple complaint investigations (CI MS #17662, CI MS #17667, CI MS #17674, CI MS #17675) from 03/25/21 to 03/29/21.

The facility was found to be in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. All complaint investigations were unsubstantiated with no deficiencies cited related to quality of care or resident neglect.

Complaint investigations CI MS #17662, #17667, #17674, and #17675 were unsubstantiated with no deficiencies cited. Issues investigated included Responsible Party Not Notified, Resident Left Soiled or Wet for Extended Time, Medication Not Given According to Physician, Resident Neglect related to Assess, Dietary Services, Rehabilitation Services, Pressure Sore Prevention, Resident Not Repositioned, and Inappropriate Feeding Assistance.

The inspection was conducted as a complaint survey on 1/13/2021 to determine compliance with state licensure requirements.

The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The complaint survey was conducted on 1/13/2021 and the facility was found to be in compliance.

A COVID-19 Focused Infection Control Survey and a Complaint Investigation (CI #17399) were conducted by the State Agency on 1/13/21 to assess infection control practices and quality of care.

The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19. The complaint was not substantiated and no deficiencies were cited.

Complaint Investigation CI #17399 was not substantiated for Infection Control/Quality of Care; the complaint lacked sufficient evidence for failing to provide infection control measures and poor quality of care.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/13/2021.

The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).

The inspection was conducted as a complaint survey to determine compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The complaint survey was conducted on 01/13/2021 and the facility was found to be in compliance.

A COVID-19 Focused Infection Control Survey and a Complaint Investigation (CI #17399) were conducted by the State Agency on 1/13/21 to assess infection control practices and quality of care.

The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19. The complaint was not substantiated and no deficiencies were cited.

Complaint Investigation CI #17399 was not substantiated for Infection Control/Quality of Care. The complaint lacked sufficient evidence for failing to provide infection control measures and poor quality of care.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/13/2021 to assess compliance with relevant federal regulations.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.

A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16653, CI MS #17197) was conducted by the State Agency.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. Both complaint investigations were unsubstantiated with no deficiencies cited, and the facility was determined to be in compliance with Medicare and Medicaid requirements.

Complaint investigations CI MS #16653 and CI MS #17197 were unsubstantiated with no deficiencies cited related to Quality of Care, Facility Staffing, Resident Neglect, Call Bell response, grooming, turning, and resident care issues.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16653, CI MS #17197) was conducted by the State Agency.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. Both complaint investigations were unsubstantiated with no deficiencies cited, and the facility was determined to be in compliance with Medicare and Medicaid requirements.

Complaint investigations CI MS #16653 and CI MS #17197 were unsubstantiated with no deficiencies cited related to Quality of Care, Facility Staffing, Resident Neglect, Call Bell response, grooming, turning, and resident care.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

A Covid-19 Focused Infection Control Survey and complaint investigation were conducted on 10/7/20 to assess compliance with infection control regulations and investigate two complaints.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. Both complaints were not substantiated due to lack of sufficient evidence of neglect or patient safety issues.

Two complaints (CI MS #16773 and CI MS #16853) were investigated and found not substantiated for Neglect/Quality of Care and patient safety respectively.

A Covid-19 Focused Infection Control Survey and complaint investigation were conducted on 10/7/20 to assess compliance with infection control regulations and investigate complaints CI MS #16773 and CI MS #16853.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. Both complaints were not substantiated due to lack of sufficient evidence of neglect, poor safety, or quality of care.

Complaint investigation CI MS #16773 was not substantiated for Neglect/Quality of Care. Complaint investigation CI MS #16853 was not substantiated for patient safety. Both complaints were not substantiated due to lack of sufficient evidence.

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.

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.

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.

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.

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.

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.

The State Survey Agency conducted a complaint investigation on 12/9/19 related to Admission, Transfer, and Discharge Rights.

The investigation was partially substantiated for Admission, Transfer, and Discharge Rights with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements of participation.

Complaint investigation was partially substantiated for Admission, Transfer, and Discharge Rights with no deficiencies cited.

The State Survey Agency conducted a complaint investigation regarding unqualified personnel and administration/personnel issues.

The investigation was unsubstantiated with no deficiencies cited, and the facility was found in compliance with Medicare and Medicaid requirements for participation.

Complaint investigation was unsubstantiated for unqualified personnel and administration/personnel with no deficiencies cited.

The State Agency conducted an annual recertification survey from 6/24/19 through 6/27/19 to assess compliance with Medicare and Medicaid Requirements of Participation.

The facility was found not in compliance with multiple requirements including infection control practices related to glucometer cleaning and hand hygiene, accuracy of assessments, care plan implementation and revision, and psychotropic medication management. An Immediate Jeopardy was identified due to failure to disinfect glucometers and perform hand hygiene, posing a risk of bloodborne pathogen transmission.

A complaint investigation was conducted at the facility on November 14, 2018.

The investigation was unsubstantiated with no deficiencies cited.

The complaint investigation was unsubstantiated with no deficiencies cited.

The State Agency conducted an annual survey from 08/07/2018 through 08/09/2018 to determine compliance with Medicare and Medicaid Requirements for participation.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to care plan implementation, activities of daily living (ADL) care, and incontinent care. Specific issues included failure to properly position a resident for eating, improper incontinent care leading to risk of urinary tract infection, and failure to fully implement care plans for residents.

The State Agency conducted a State Licensure survey from 08/07/18 through 08/09/18 to determine compliance with the State Minimum Standards for the Aged and Infirm.

The facility failed to meet licensure requirements related to activities of daily living and urinary incontinence care. Deficiencies included failure to properly position a resident dependent on staff for bed mobility to eat comfortably and improper incontinent care that could lead to urinary tract infections.