Inspection Reports for Ocean Springs Health and Rehabilitation Center
MS, 39564
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 8, 2026, was a complaint investigation in which the facility was found to be in compliance with no deficiencies cited. Prior inspections showed a pattern of deficiencies primarily related to residents' rights, activities of daily living assistance, infection control, food safety, and care plan implementation. Notable past issues included Immediate Jeopardy findings for inadequate supervision leading to resident elopements and failure to provide CPR due to misidentification of code status, both of which were resolved after corrective actions. Most complaint investigations were unsubstantiated, with one substantiated case involving medication diversion in 2022 and another involving verbal abuse in 2023; no fines or license actions were listed in the available reports. The facility’s recent inspections indicate improvement, with the latest surveys showing compliance following earlier citations.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
93% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 107
Capacity: 115
Deficiencies: 0
Date: Jan 8, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (MS #2690736) related to quality of care, physical environment, and infection control at the facility.
Complaint Details
Complaint Investigation MS #2690736 was investigated related to quality of care, physical environment, and infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 8, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2690736, related to quality of care, physical environment, and infection control at the facility.
Complaint Details
Complaint Investigation MS #2690736 was investigated related to quality of care, physical environment, and infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.
Inspection Report
Follow-Up
Census: 103
Capacity: 115
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
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.
Findings
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.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
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.
Findings
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.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 11, 2025
Visit Reason
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.
Complaint Details
Complaint investigations were conducted for a resident-on-resident incident and misappropriation of funds; no citations were related to these complaints.
Findings
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.
Deficiencies (4)
Failure to ensure residents' rights including dignity in toileting preferences, privacy regarding hospice signage, provision of Resident Bill of Rights at admission, and assistance with obtaining personal identification.
Failure to provide assistance with activities of daily living including incontinent care and shaving for dependent residents.
Failure to maintain food quality and hygienic practices including presence of overly ripe produce, improperly stored and expired food, and unsanitary handling of ready-to-eat food.
Failure to implement timely contact isolation precautions for Resident #47 and enhanced barrier precautions during wound care for Resident #4.
Report Facts
Number of sampled residents with deficiencies: 4
Number of sampled residents with ADL deficiencies: 2
Number of kitchen observations with food safety issues: 2
Number of sampled residents with infection control deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #109's toileting care and use of briefs. |
| Director of Nursing | DON | Interviewed regarding expectations for resident dignity, ADL care, and infection control practices. |
| Admissions Coordinator | Interviewed regarding failure to provide Resident Bill of Rights and admission documents to Resident #26. | |
| Social Services Director | Interviewed regarding Resident #48's request for assistance obtaining personal identification. | |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding incontinent care for Resident #109. |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding shaving care for Resident #91. |
| Dietary Manager | DM | Interviewed regarding food safety deficiencies and staff education. |
| Registered Nurse #2 | RN | Interviewed regarding infection control failures for Resident #47. |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding failure to wear gowns during wound care for Resident #4. |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding failure to wear gowns during wound care for Resident #4. |
| Nurse Practitioner | NP | Observed providing wound care without gowns for Resident #4. |
| Administrator | Interviewed regarding expectations for infection control and resident care. |
Inspection Report
Annual Inspection
Census: 108
Capacity: 115
Deficiencies: 11
Date: Sep 11, 2025
Visit Reason
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.
Complaint Details
The survey included complaint investigations for a resident-on-resident incident and misappropriation of funds. No citations were related to the complaint investigations.
Findings
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.
Deficiencies (11)
Failed to ensure a resident’s right to dignity and respect when staff required her to wear a brief against her preference instead of providing a bedpan or assistance to the bathroom.
Failed to honor a resident’s request for assistance in obtaining personal identification, resulting in a delay of more than one year without follow-up affecting autonomy and community access.
Failed to provide residents or their representatives with copies of the Resident Bill of Rights and admission documents at the time of admission.
Failed to ensure a resident's right to personal privacy by posting identifying hospice information on a resident’s door.
Failed to implement abuse prevention policy by not reporting and investigating an allegation of misappropriation of resident property in a timely manner.
Failed to provide assistance with activities of daily living for residents dependent on staff, related to incontinence care and shaving.
Failed to post daily nurse staffing information in a prominent place readily accessible to residents, staff, and visitors for four days of survey.
Failed to maintain food quality and hygienic practices in accordance with professional standards for food safety related to overly ripe produce, improperly stored food, exposed food, expired food, and unsanitary handling of ready-to-eat food.
Failed to accurately report staffing data to CMS using payroll and other verifiable sources in a uniform format for one quarter, resulting in triggering for excessively low weekend staffing, no RN hours, and no licensed nursing coverage 24 hours/day.
Failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to Payroll Based Journal reporting and QAPI program effectiveness.
Failed to prevent the possible spread of infection by not implementing contact isolation precautions timely for one resident and enhanced barrier precautions when providing wound care for another resident.
Report Facts
Deficiencies cited: 11
Licensed beds: 115
Resident census: 108
PBJ reporting quarter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #109 toileting and brief use. |
| Director of Nursing | Director of Nursing | Interviewed regarding resident dignity, staffing, infection control, and wound care practices. |
| Social Services Director | Social Services Director | Interviewed regarding Resident #109 toileting preferences and Resident #48 identification assistance. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding Resident #109 incontinence care. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding Resident #106 misappropriation incident and Resident #91 shaving. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Responsible for staffing schedule and PBJ data entry. |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and storage deficiencies. |
| Administrator | Administrator | Interviewed regarding QAPI program, PBJ reporting, infection control, and overall facility expectations. |
| Nurse Practitioner | Nurse Practitioner | Observed and interviewed regarding wound care and PPE use. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed and interviewed regarding wound care and PPE use. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide adequate supervision and assessment and monitoring of a wandering alarm device to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Distance Resident walked: 0.7
Duration Resident unsupervised: 30
Date Immediate Jeopardy removed: Feb 10, 2025
Date of corrective action completion: Feb 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Notified Director of Nurses and involved in investigation and assessment of Resident #1 after elopement. |
| CNA #1 | Certified Nursing Assistant | Reported seeing Resident #1 walking along the highway and assisted in locating and returning the resident. |
| DON | Director of Nursing | Reported incident to State Agency, attended QAPI meeting, confirmed system malfunction and corrective actions. |
| Maintenance Director | Maintenance Director | Tested wander guard system and exit doors, confirmed malfunction of transmitters, ordered replacements. |
| Administrator | Facility Administrator | Reported incident details, coordinated investigation and corrective actions. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 115
Deficiencies: 2
Date: Feb 13, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to implement care plan interventions for Resident #1 related to wandering and elopement risk, including monitoring the wander guard device daily.
Failure to provide adequate supervision and monitoring of a wandering alarm device to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Resident census: 102
Total licensed capacity: 115
Distance walked by Resident #1: 0.7
Duration unsupervised: 30
Temperature: 75
Wind speed: 9.21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Working during elopement, did not check wander guard transmitter functionality |
| CNA #1 | Certified Nurse Aide | Reported seeing Resident #1 walking along highway and assisted in locating resident |
| Director of Nursing | Director of Nursing | Confirmed importance of care plan implementation and monitoring of wander guard devices |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy, described incident and corrective actions |
| Maintenance Director | Maintenance Director | Tested wander guard system and confirmed malfunction, replaced transmitters |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
The State Agency conducted a complaint investigation related to neglect and staffing at the facility.
Complaint Details
Complaint investigation MS #27532 related to neglect and staffing; no deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 100
Capacity: 115
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27532, related to neglect and staffing at the facility.
Complaint Details
Complaint Investigation MS #27532 was related to neglect and staffing and was found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The State Agency conducted complaint investigations related to pressure sores, staffing, food palatability, verbal abuse, call bell response, and resident rights at the facility.
Complaint Details
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.
Findings
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.
Inspection Report
Complaint Investigation
Census: 102
Capacity: 115
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The State Agency conducted complaint investigations related to pressure sores, staffing, food palatability, verbal abuse, call bell response, and resident rights.
Complaint Details
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.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigations.
Report Facts
Licensed beds: 115
Census: 102
Inspection Report
Complaint Investigation
Census: 100
Capacity: 115
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
The State Agency conducted two complaint investigations regarding Misappropriation of Property, Physical Environment, Physician Services, Resident Abuse, and Safety at the facility.
Complaint Details
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.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigations.
Report Facts
Census: 100
Total licensed capacity: 115
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
The State Agency conducted complaint investigations regarding Misappropriation of Property, Physical Environment, Physician Services, Resident Abuse, and Safety at the facility.
Complaint Details
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.
Findings
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.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 21, 2024
Visit Reason
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.
Complaint Details
The visit included five complaint investigations conducted from 4/15/24 through 4/18/24; the facility was found in compliance.
Findings
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.
Report Facts
Complaint Investigations: 5
Inspection Report
Follow-Up
Census: 103
Capacity: 115
Deficiencies: 0
Date: May 21, 2024
Visit Reason
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.
Complaint Details
The visit included investigation of five Complaint Investigations conducted from 4/15/24 through 4/18/24.
Findings
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.
Report Facts
Licensed beds: 115
Census: 103
Complaint Investigations: 5
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 21, 2024
Visit Reason
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.
Complaint Details
The visit included five complaint investigations conducted from 4/15/24 through 4/18/24; the facility was found in compliance.
Findings
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.
Report Facts
Complaint Investigations: 5
Inspection Report
Follow-Up
Census: 103
Capacity: 115
Deficiencies: 0
Date: May 21, 2024
Visit Reason
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.
Findings
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.
Report Facts
Licensed beds: 115
Census: 103
Number of complaint investigations: 5
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 18, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to ensure a resident's right for a dignified dining experience by not providing timely incontinence care, resulting in odors and discomfort for Resident #38.
Failure to provide timely incontinence care for six residents, resulting in skin excoriations and increased risk of urinary tract infections.
Failure to ensure resident safety by not assessing and developing interventions for a resident with known substance use disorder (Resident #57).
Failure to maintain effective infection control program, evidenced by nurse touching medications with bare hands and CNAs discarding soiled linens and briefs on the floor during care.
Report Facts
Sampled residents: 22
Residents with incontinence care issues: 6
Residents with substance abuse disorder: 1
Deficiency citations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in failure to provide timely incontinence care to Resident #38. |
| CNA #10 | Certified Nurse Aide | Named in failure to provide timely incontinence care to Resident #38. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for resident care and infection control; involved in staff inservices and monitoring. |
| RN #3 | Registered Nurse | Observed touching medications with bare hands during administration. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding incontinence care and infection control practices. |
| RN #2 | Registered Nurse/Infection Preventionist | Interviewed regarding infection control policies and concerns. |
| Medical Director | Medical Director | Interviewed regarding resident with substance use disorder and need for referral to program. |
Inspection Report
Annual Inspection
Census: 104
Capacity: 115
Deficiencies: 7
Date: Apr 18, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with five complaint investigations at the facility from 4/15/24 through 4/18/24.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Failed to ensure a resident's right for a dignified dining experience when staff did not provide incontinence care resulting in odors in the resident's room.
Failed to develop and implement comprehensive care plans for residents with UTI, substance use disorder, and low air loss mattress.
Failed to ensure resident safety by not assessing risk of substance use and not developing interventions for a resident with substance use disorder.
Failed to provide timely incontinence care for six residents resulting in skin excoriations and improper use of multiple briefs.
Failed to accurately submit Payroll Based Journal staffing data to CMS for Q1 FY 2023, resulting in excessively low weekend staffing reporting.
Failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program, with repeated deficiencies in residents' rights and wound care.
Failed to maintain an infection prevention and control program, evidenced by a nurse touching medications with bare hands and CNAs discarding soiled linens and briefs on the floor.
Report Facts
Census: 104
Total Capacity: 115
Deficiencies cited: 7
Residents sampled: 22
Residents monitored for skin integrity: 3
Residents monitored for bowel and bladder care: 4
Audit frequency: 3
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in findings related to incontinence care, care plan development, infection control, and QAPI monitoring |
| Administrator | Administrator | Named in findings related to facility oversight, QAPI, and staffing reporting |
| Registered Nurse #3 | Registered Nurse | Observed touching medication with bare hands |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed residents wearing two briefs and discussed infection control |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Responsible for staffing schedules and unaware of PBJ reporting errors |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 18, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure a Pressure Ulcer intervention related to an air mattress was continued after a room change for one resident.
Report Facts
Complaint Investigations: 4
Residents reviewed for pressure ulcers: 3
Braden Scale score: 17
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Doctor (MD) | Apologized to Resident #261's family member during care plan meeting for failure to move low air loss mattress | |
| Director of Nursing (DON) | Confirmed failure to move low air loss mattress for Resident #261 and initiated audits and staff inservices |
Inspection Report
Annual Inspection
Census: 104
Capacity: 115
Deficiencies: 2
Date: Apr 18, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to develop and implement comprehensive care plan interventions for a resident with a Urinary Tract Infection (Resident #55), a resident with Substance Use Disorder (Resident #57), and failed to implement care plan intervention related to a low air loss mattress for Resident #261.
Failed to ensure a Pressure Ulcer intervention related to an air mattress was continued after a room change for Resident #261.
Report Facts
Census: 104
Total Capacity: 115
Deficiencies cited: 7
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Responsible for resident care plans; confirmed no care plan developed for Resident #55's UTI |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Care plan nurse; confirmed no care plan developed for Resident #57's substance use disorder |
| Director of Nursing | Director of Nursing | Confirmed lack of care plans for UTI and low air loss mattress; responsible for auditing care plans and interventions |
| Medical Doctor | Medical Doctor | Apologized to Resident #261's family for failure to move low air loss mattress after room change |
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 102
Capacity: 115
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to review the correct code status and implement the baseline care plan resulted in Resident #1 not receiving CPR and emergency services.
Report Facts
Licensed beds: 115
Resident census: 102
Number of nurses educated: 88
Date of incident: Jul 19, 2023
Date Immediate Jeopardy identified: Jul 25, 2023
Date Immediate Jeopardy removed: Jul 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse who pulled wrong resident's chart and failed to initiate CPR |
| LPN #2 | Licensed Practical Nurse | Nurse who confirmed DNR status incorrectly and communicated with family |
| RN #1 | Registered Nurse | Nurse who made death pronouncement without verifying resident identity or code status |
| DON | Director of Nursing | Facility administrator involved in investigation and corrective actions |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and involved in corrective action plan |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 115
Deficiencies: 3
Date: Jul 26, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency services to Resident #1 due to pulling the wrong resident's chart with a Do Not Resuscitate (DNR) order.
Failure to develop and implement a baseline care plan for Resident #1 that included CPR instructions.
Failure to notify the resident's family of the death in a timely manner.
Report Facts
Licensed beds: 115
Census: 102
Number of residents sampled: 4
Number of nurses educated: 88
Number of non-nursing staff educated: 35
Number of suspended staff: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Pulled wrong resident's chart leading to failure to initiate CPR |
| LPN #2 | Licensed Practical Nurse | Confirmed resident was unresponsive but did not verify correct resident chart |
| RN #1 | Registered Nurse | Made death pronouncement without verifying resident identity or code status |
| Director of Nursing | Director of Nursing | Investigated incident and confirmed failure to follow care plan and policies |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and oversaw corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 16, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 16, 2023
Visit Reason
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.
Complaint Details
The visit was related to a complaint survey completed on 2023-04-19. The review confirmed corrective actions were implemented and compliance was restored.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 9, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 5/9/23 regarding a complaint for neglect.
Complaint Details
Complaint Investigation MS #21357 for neglect; no deficiencies cited during this investigation.
Findings
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.
Inspection Report
Complaint Investigation
Census: 100
Capacity: 115
Deficiencies: 0
Date: May 9, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #21357, at the facility on 5/9/23 for resident neglect.
Complaint Details
Complaint Investigation MS #21357 for resident neglect was conducted and found no deficiencies.
Findings
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.
Report Facts
License capacity: 115
Census: 100
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility failed to ensure residents were free from abuse as evidenced by a verbal and physical altercation between Resident #1 and CNA #1.
Report Facts
Complaints investigated: 3
Date of complaint incident: Feb 18, 2023
Date of CNA termination: Feb 24, 2023
Resident interviews: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Conducted skin observation, suspended and discharged CNA #1, reported allegation of abuse to State Agency | |
| Registered Nurse #1 | Witnessed and reported verbal altercation and physical struggle between Resident #1 and CNA #1, called police | |
| Certified Nurse Aide #1 | Involved in verbal and physical altercation with Resident #1, suspended and terminated for unprofessional conduct | |
| Registered Nurse Supervisor | Completed resident interviews post-incident to monitor for abuse | |
| Administrator | Set expectations for staff behavior, notified following incident, confirmed termination of CNA #1 | |
| Registered Nurse #2 | Confirmed hearing verbal altercation between Resident #1 and CNA #1 |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 110
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure residents were free from verbal abuse as evidenced by a verbal altercation and physical struggle between Resident #1 and CNA #1.
Report Facts
Licensed beds: 110
Resident census: 100
Complaints investigated: 3
Resident interviews: 3
Duration of follow-up interviews: 3
Incident date: Feb 18, 2023
Termination date: Feb 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Witnessed and reported the verbal altercation and physical struggle involving Resident #1 and CNA #1 |
| CNA #1 | Certified Nurse Aide | Involved in verbal abuse and physical struggle with Resident #1; suspended and terminated |
| Director of Nursing | Director of Nursing | Conducted investigation, suspended and terminated CNA #1, initiated staff training and resident interviews |
| RN #2 | Registered Nurse | Confirmed verbal altercation between Resident #1 and CNA #1 |
| Administrator | Facility Administrator | Set expectations for staff behavior and was notified of the incident and subsequent actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 5, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Inspection Report
Complaint Investigation
Census: 90
Capacity: 115
Deficiencies: 0
Date: Dec 5, 2022
Visit Reason
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.
Complaint Details
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.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. None of the complaints were substantiated and no deficiencies were cited.
Report Facts
Licensed beds: 115
Census: 90
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 11, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect a resident from misappropriation of medication involving a missing card of Percocet 5/325 mg tablets.
Report Facts
Medication doses missing: 15
Dates of investigation: 2
Termination date: Aug 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Involved in medication diversion and terminated from employment |
| LPN #1 | Licensed Practical Nurse | Reported the medication discrepancy |
| Director of Nursing | Director of Nursing | Conducted investigation and reported findings |
| Administrator | Facility Administrator | Interviewed regarding the medication diversion incident |
| Pharmacy Consultant | Pharmacy Consultant | Confirmed medication delivery and reported diversion to Board of Pharmacy |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 115
Deficiencies: 1
Date: Aug 11, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect a resident from misappropriation of medication, specifically a missing card of Percocet 5/325 mg tablets that was subtracted from the narcotic log by LPN #2 without a witness and without explanation.
Report Facts
Facility licensed capacity: 115
Resident census: 82
Medication doses missing: 15
Date of medication delivery: Jul 22, 2022
Date of discrepancy report: Jul 26, 2022
Termination date: Aug 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported medication discrepancy involving Resident #1's Percocet |
| LPN #2 | Licensed Practical Nurse | Subtracted medication card from narcotic log, failed to explain missing medication, terminated from employment |
| Director of Nursing | Director of Nursing | Conducted investigation, interviewed staff, reported incident to authorities |
| Administrator | Administrator | Informed of missing medication and investigation |
| Pharmacy Consultant | Pharmacy Consultant | Confirmed medication delivery and reported diversion to Board of Pharmacy |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 11, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Medication diversion
Inspection Report
Complaint Investigation
Census: 82
Capacity: 115
Deficiencies: 1
Date: Aug 11, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Medication diversion
Report Facts
Facility license capacity: 115
Census: 82
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 115
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility on 6/17/22 regarding an allegation of sexual abuse.
Complaint Details
Complaint investigation (CI MS #18804) for sexual abuse was not substantiated.
Findings
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.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 115
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 6/17/22 in response to complaint MS #18804.
Complaint Details
Complaint MS #18804 was investigated and found not substantiated.
Findings
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.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 3, 2022
Visit Reason
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).
Findings
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.
Inspection Report
Deficiencies: 0
Date: May 3, 2022
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements during the survey.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 29, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to treat a resident in a dignified manner by not covering the resident during incontinence/catheter care (Resident #77).
Failed to resolve a resident's grievance regarding missing personal property (Resident #20).
Failed to ensure residents dependent on staff for showering, shaving, and nail care received those services (Residents #48, #49, #56, #58, #60).
Failed to clean residents' wounds according to professional standards (Residents #49 and #63).
Report Facts
Complaint investigations: 6
Residents reviewed for ADL assistance: 6
Residents with bathing deficiencies: 5
Wound care observations: 4
Residents with wound care deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Failed to cover resident during incontinence/catheter care. |
| Director of Nursing | Conducted assessments, interviews, and oversaw corrective actions related to deficiencies. | |
| Registered Nurse #2 | Registered Nurse | Performed wound care with improper technique. |
| Social Services Designee | Involved in grievance investigation and communication with resident's family. | |
| Interim Administrator | Interviewed regarding unresolved grievance. |
Inspection Report
Annual Inspection
Census: 78
Capacity: 115
Deficiencies: 3
Date: Apr 29, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to ensure residents dependent on staff for showering, shaving, and nail care received those services for five of six residents reviewed.
Failure to clean residents' wounds according to professional standards for two of four wound care observations.
Failure to prevent a significant medication error when a resident did not receive sliding scale insulin per physician's orders.
Report Facts
Beds licensed: 115
Resident census: 78
Number of complaint investigations: 6
Deficiency citations: 8
Residents reviewed for ADL assistance: 6
Residents with ADL deficiencies: 5
Wound care observations: 4
Wound care deficiencies: 2
Sliding scale insulin errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in medication error finding for failure to enter sliding scale insulin order correctly |
| Registered Nurse #2 | Registered Nurse | Named in wound care deficiency for improper wound cleaning technique |
| Director of Nursing | Director of Nursing | Interviewed regarding ADL care, wound care, and medication administration findings |
| Social Services Designee | Social Services Designee | Interviewed regarding resident grievances and podiatry referrals |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 29, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to treat a resident in a dignified manner by not covering the resident during incontinence/catheter care.
Failed to resolve a resident's grievance regarding personal property.
Failed to ensure residents dependent on staff for showering, shaving, and nail care received those services for five of six residents reviewed.
Failed to clean residents' wounds according to professional standards for two of four wound care observations.
Failed to remove expired food items from pantry, failed to date open food items, and failed to reseal a hamburger bun package in the kitchen.
Report Facts
Complaint investigations: 6
Residents reviewed for ADL assistance: 6
Residents with bathing deficiencies: 5
Wound care observations: 4
Residents with wound care deficiencies: 2
Kitchen observations: 3
Expired food items found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Failed to cover resident during incontinent/catheter care. |
| Director of Nursing | Conducted assessments, interviews, and oversaw corrective actions related to dignity, bathing, wound care, and grievance investigations. | |
| Registered Nurse #2 | Registered Nurse | Observed providing improper wound care to residents #49 and #63. |
| Social Services Designee (SSD) | Involved in grievance investigation and communication with resident and family. | |
| Chef | Responsible for food safety, failed to remove expired food and reseal food packages. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 29, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to treat a resident in a dignified manner by not covering the resident during incontinence/catheter care.
Failed to resolve a resident's grievance regarding personal property.
Failed to ensure residents dependent on staff for showering, shaving, and nail care received those services for five of six residents reviewed.
Failed to clean residents' wounds according to professional standards for two of four wound care observations.
Failed to remove expired food items from pantry, failed to date open food items, and failed to reseal a hamburger bun package in the kitchen.
Report Facts
Number of complaint investigations: 6
Number of residents reviewed for ADL assistance: 6
Number of residents with bathing deficiencies: 5
Number of wound care observations: 4
Number of wounds with improper care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Failed to cover resident during incontinent/catheter care. |
| Registered Nurse #2 | Registered Nurse | Performed wound care with improper technique. |
| Director of Nursing | Director of Nursing | Interviewed regarding deficiencies and oversaw corrective actions. |
| Chef | Chef | Responsible for food storage and removal of expired items; failed to remove expired food and properly seal food items. |
| Social Services Designee | Social Services Designee | Involved in grievance investigation and communication with resident's family. |
Inspection Report
Annual Inspection
Census: 78
Capacity: 115
Deficiencies: 7
Date: Apr 29, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Failed to treat a resident in a dignified manner by not covering the resident during incontinent/catheter care.
Failed to resolve a resident's grievance regarding personal property (missing ring).
Failed to thoroughly investigate a resident's allegation of misappropriation of personal property.
Failed to ensure dependent residents received necessary ADL care including showers, shaving, and nail care.
Failed to clean residents' wounds according to professional standards for two wound care observations.
Failed to prevent significant medication error when sliding scale insulin was not administered per physician's orders.
Failed to remove expired food items, date open food items, and reseal food packages in the kitchen.
Report Facts
Beds licensed: 115
Census: 78
Complaint investigations: 6
Deficiency citations: 8
Resident #234 blood glucose readings: 10
Resident #48 missed showers: 9
Resident #49 missed showers: 8
Resident #58 missed showers: 11
Resident #60 missed showers: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Failed to cover resident during incontinent/catheter care |
| Director of Nursing | Director of Nursing | Conducted assessments, in-serviced staff, and confirmed deficiencies |
| Social Services Director | Social Services Director | In-serviced on grievance policy and investigated missing ring grievance |
| Assistant Director of Nursing | Assistant Director of Nursing | Reported misappropriation allegation, assessed resident #234, conducted medication discrepancy report, and in-serviced staff |
| Registered Nurse #2 | Registered Nurse | Performed wound care with improper technique |
| LPN #4 | Licensed Practical Nurse | Failed to enter sliding scale insulin order correctly |
| Chef | Chef | Failed to remove expired food, date open items, and reseal food packages |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 115
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
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.
Complaint Details
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).
Findings
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.
Report Facts
Census: 87
Total licensed capacity: 115
Inspection Report
Complaint Investigation
Census: 87
Capacity: 115
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
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.
Complaint Details
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).
Findings
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.
Report Facts
Census: 87
Total licensed capacity: 115
Inspection Report
Complaint Investigation
Census: 90
Capacity: 110
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
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.
Complaint Details
Complaint Investigation MS #17826 was substantiated related to elopement. Complaints MS #17819 and MS #17827 related to abuse were unsubstantiated.
Findings
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.
Deficiencies (1)
Failure to provide adequate staff supervision to prevent Resident #3's elopement from the facility on 5/22/21.
Report Facts
Census: 90
Total Capacity: 110
Duration of Elopement: 92
Distance from Facility: 720
Date of Elopement: May 22, 2021
Date of Survey Completion: Jun 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Found Resident #3 unsupervised in a parked vehicle and assisted her back to the facility |
| CNA #2 | Certified Nursing Assistant | Found Resident #3 unsupervised in a parked vehicle and assisted her back to the facility |
| LPN #2 | Licensed Practical Nurse | Assessed Resident #3 for signs and symptoms of injury after elopement |
| RN #2 | Registered Nurse / Risk Manager | Provided information on wandering residents and facility policies |
| Director of Operations | Demonstrated door alarm system and exit door security measures | |
| Administrator | Interviewed regarding wandering residents and facility response |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 110
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
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.
Complaint Details
The complaint investigation CI MS #17826 was substantiated related to elopement. CI MS #17819 and CI MS #17827 were unsubstantiated related to abuse.
Findings
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.
Deficiencies (1)
Failure to provide adequate staff supervision to prevent Resident #3's elopement from the facility on 5/22/21.
Report Facts
Census: 90
Total Capacity: 110
Time Resident Missing: 92
Date of Elopement: May 22, 2021
Date of Survey: Jun 10, 2021
Date Immediate Jeopardy Removed: May 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Found Resident #3 unsupervised in a parked vehicle and assisted her back to the facility |
| CNA #2 | Certified Nursing Assistant | Found Resident #3 unsupervised in a parked vehicle and assisted her back to the facility |
| LPN #2 | Licensed Practical Nurse | Assessed Resident #3 for signs and symptoms of injury and pain after elopement |
| RN #2 | Registered Nurse / Risk Manager | Provided information about wandering residents and facility policies |
| Administrator | Interviewed regarding the elopement incident and facility response | |
| Director of Operations | Demonstrated door alarm systems and security measures |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 115
Deficiencies: 0
Date: Mar 29, 2021
Visit Reason
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.
Complaint Details
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.
Findings
The investigations were unsubstantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Report Facts
Facility licensed beds: 115
Resident census: 89
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
The inspection was conducted as a complaint survey on 1/13/2021 to determine compliance with state licensure requirements.
Complaint Details
The complaint survey was conducted on 1/13/2021 and the facility was found to be in compliance.
Findings
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.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 115
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/13/2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
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.
Complaint Details
The complaint survey was conducted on 01/13/2021 and the facility was found to be in compliance.
Findings
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.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 115
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Census: 74
Total licensed capacity: 115
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/13/2021 to assess compliance with relevant federal regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 115
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16653, CI MS #17197) was conducted by the State Agency.
Complaint Details
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.
Findings
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.
Report Facts
Census: 96
Total licensed capacity: 115
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 96
Capacity: 115
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16653, CI MS #17197) was conducted by the State Agency.
Complaint Details
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.
Findings
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.
Report Facts
Census: 96
Total licensed capacity: 115
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 103
Capacity: 115
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
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.
Complaint Details
Two complaints (CI MS #16773 and CI MS #16853) were investigated and found not substantiated for Neglect/Quality of Care and patient safety respectively.
Findings
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.
Report Facts
Census: 103
Total licensed capacity: 115
Inspection Report
Complaint Investigation
Census: 103
Capacity: 115
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Census: 103
Total licensed capacity: 115
Inspection Report
Abbreviated Survey
Census: 103
Capacity: 115
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 103
Total licensed capacity: 115
Inspection Report
Abbreviated Survey
Census: 96
Capacity: 115
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 96
Capacity: 115
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 115
Deficiencies: 0
Date: Dec 9, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation on 12/9/19 related to Admission, Transfer, and Discharge Rights.
Complaint Details
Complaint investigation was partially substantiated for Admission, Transfer, and Discharge Rights with no deficiencies cited.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 29, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation regarding unqualified personnel and administration/personnel issues.
Complaint Details
Complaint investigation was unsubstantiated for unqualified personnel and administration/personnel with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited, and the facility was found in compliance with Medicare and Medicaid requirements for participation.
Inspection Report
Annual Inspection
Census: 93
Capacity: 115
Deficiencies: 8
Date: Jun 27, 2019
Visit Reason
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.
Findings
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.
Deficiencies (8)
Failure to wash hands and disinfect glucometer per manufacturer's recommendations for blood glucose testing, posing a threat of bloodborne pathogen cross-contamination.
Failure to accurately code Minimum Data Set (MDS) to include Hospice services for one resident.
Failure to implement care plan related to catheter care for one resident, including keeping urinary drainage bag off the floor.
Failure to revise care plan related to pressure ulcers for one resident to reflect current wound status.
Failure to meet professional standards of quality related to infection control and glucometer cleaning and hand hygiene.
Failure to document rationale for declining pharmacy consultant recommendations for gradual dose reduction of psychotropic medications for three residents.
Failure to establish and maintain an infection prevention and control program that includes proper cleaning and disinfection of glucometers and hand hygiene.
Urinary catheter drainage bag observed laying on the floor for one resident, posing infection control risk.
Report Facts
Census: 93
Total Capacity: 115
Residents receiving blood glucose monitoring: 24
Nurses on duty: 6
Psychotropic medication reviews: 79
Residents with urinary catheters observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in infection control deficiency related to glucometer cleaning and hand hygiene |
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency related to glucometer cleaning and hand hygiene |
| LPN #2 | Licensed Practical Nurse | Named in infection control deficiency related to glucometer cleaning and hand hygiene |
| RN #1 | Registered Nurse | Named in catheter care deficiency |
| RN #2 | Infection Control Nurse/Risk Management Nurse | Provided infection control education and monitoring |
| RN #3 | Staff Development Nurse | Provided infection control education |
| RN #4 | Registered Nurse | Observed and interviewed regarding infection control practices |
| Director of Nursing | Director of Nursing | Oversaw infection control corrective actions and education |
| Administrator | Administrator | Notified of Immediate Jeopardy and led staff education |
| Medical Director | Medical Director | Interviewed regarding infection control and psychotropic medication rationales |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2018
Visit Reason
A complaint investigation was conducted at the facility on November 14, 2018.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 96
Capacity: 115
Deficiencies: 3
Date: Aug 9, 2018
Visit Reason
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.
Findings
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.
Deficiencies (3)
Failed to implement care plan related to Activities of Daily Living for Resident #11 and urinary incontinence for Resident #15.
Failed to ensure a resident dependent on staff for bed mobility was positioned properly to eat comfortably (Resident #11).
Failed to provide incontinent care in a manner to prevent urinary tract infection for Resident #15.
Report Facts
Licensed beds: 115
Census: 96
Care plans reviewed: 20
Residents with bowel/bladder incontinence: 26
BIMS score: 10
Urine culture colony count: 100000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #11's positioning and care plan implementation |
| LPN #3 | Licensed Practical Nurse / Care Plan Coordinator | Confirmed care plan details for Resident #15 and interventions |
| CNA #1 | Certified Nursing Assistant | Observed and interviewed regarding Resident #11's positioning and feeding |
| CNA #2 | Certified Nursing Assistant | Observed providing incontinent care to Resident #15 and feeding Resident #11 |
| CNA #3 | Certified Nursing Assistant | Assisted CNA #2 with incontinent care for Resident #15 |
| Director of Nursing | Director of Nursing (DON) | Provided interviews and oversaw corrective actions related to care plan implementation and incontinent care |
| Risk Manager | Risk Manager | Conducted in-services and audits related to care plan implementation and incontinent care |
Inspection Report
Annual Inspection
Census: 96
Capacity: 115
Deficiencies: 2
Date: Aug 9, 2018
Visit Reason
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.
Findings
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.
Deficiencies (2)
Failure to ensure a resident dependent on staff for bed mobility was pulled up and positioned in bed to eat comfortably.
Failure to provide incontinent care in a manner to prevent the possibility of a Urinary Tract Infection for one resident.
Report Facts
Licensed beds: 115
Resident census: 96
Residents reviewed: 20
Residents with incontinent care observations: 3
Residents with bowel/bladder incontinence: 26
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in deficiency related to improper positioning of Resident #11 for eating |
| CNA #2 | Certified Nursing Assistant | Named in deficiencies related to improper positioning of Resident #11 and incontinent care for Resident #15 |
| CNA #3 | Certified Nursing Assistant | Assisted CNA #2 with incontinent care for Resident #15 |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding Resident #11's positioning for eating |
| Director of Nursing | Director of Nursing (DON) | Provided education and conducted rounds related to deficiencies |
| Risk Manager | Risk Manager | Conducted in-services and rounds related to incontinent care and positioning |
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