47 Reports
Inspection Report — May 26, 2026
Complaint Investigation
Date: May 26, 2026
Visit Reason
On 05/26/26 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 04/22/26. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint survey was reviewed and the facility was found to have corrected the deficient practice; no deficiencies were cited.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 05/25/26. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 22, 2026
Complaint Investigation
Date: Apr 22, 2026
Visit Reason
The State Agency conducted five Complaint Investigations (CI MS #2974588, CI MS #2974553, CI MS #2974575, CI MS #2959996, and CI MS #2808770) at the facility from 4/20/26 through 4/22/26. The investigations included abuse, resident rights, infection control, quality of care, neglect, and nursing services.
Complaint Details
Five complaint investigations were conducted: CI MS #2974588 (abuse), CI MS #2974553 (resident rights and infection control), CI MS #2974575 (quality of care, abuse, nursing services), CI MS #2808770 (abuse, neglect, quality of care), and CI MS #2959996 (quality of care, neglect, abuse, nursing services). Only CI MS #2959996 was substantiated with a deficiency cited (F0690). The others had no citations.
Findings
The facility was found not in compliance due to failure to timely assess and respond to a resident's complaint of catheter-related discomfort, resulting in a deficiency cited under F0690.
Deficiencies (1)
F0690 - The facility failed to ensure timely assessment and management of an indwelling catheter for one resident, resulting in delayed catheter change and potential complications.
Report Facts
Complaint investigations conducted: 5
Deficiencies cited: 1
Inspection Report — Apr 22, 2026
Complaint Investigation
Date: Apr 22, 2026
Visit Reason
The State Agency conducted five Complaint Investigations (CI MS #2974588, CI MS #2974553, CI MS #2974575, CI MS #2959996, and CI MS #2808770) at the facility from 4/20/26 through 4/22/26. CI MS #2974588 was investigated for abuse, CI MS #2974553 for resident rights and infection control, CI MS #2974575 for quality of care, abuse, and nursing services, CI MS #2808770 for abuse, neglect, and quality of care with no citations, and CI MS #2959996 for quality of care, neglect, abuse, and nursing services with M620 cited.
Complaint Details
CI MS #2959996 was investigated for quality of care, neglect, abuse, and nursing services and resulted in citation of M620. Other complaint investigations had no citations.
Findings
The facility was found not in compliance with state licensure requirements due to failure to timely assess and respond to a resident's complaint of catheter-related discomfort, resulting in a citation for M620.
Deficiencies (1)
M620 - The facility failed to ensure an indwelling catheter was managed to prevent complications when nursing staff did not timely assess and respond to a resident's complaint of catheter discomfort, delaying catheter change for over five hours after notification.
Report Facts
Complaint Investigations conducted: 5
Deficiencies cited: 1
Inspection Report — Mar 30, 2026
Complaint Investigation
Date: Mar 30, 2026
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 02/23/26. The facility confirmed corrective measures were in place and compliance was sustained.
Complaint Details
CI MS#26995 - Complaint survey completed on 02/23/26; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements as of 03/28/26. No deficiencies were cited during this desk review.
Report Facts
Complaint survey date: Feb 23, 2026
Inspection Report — Feb 23, 2026
Complaint Investigation
Date: Feb 23, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #2739946) at the facility on 02/23/2026 for quality of care, neglect, nursing services, staffing, and environment. The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement, and cited M225 due to identification of a separate deficient practice unrelated to the CI allegations.
Complaint Details
CI MS #2739946 was investigated for quality of care, neglect, nursing services, staffing, and environment. The SA determined the facility was not in compliance and cited M225 due to a separate deficient practice unrelated to the CI allegations.
Findings
The facility failed to designate a licensed nurse to serve as the charge nurse responsible for supervision of total nursing activities for three of three shifts, as the nurse identified as the charge nurse on the 7:00 AM–3:00 PM shift simultaneously functioned as the treatment nurse, and no charge nurse was designated for the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts. This deficiency had the potential to affect all 57 residents residing in the facility.
Deficiencies (1)
M0225 - The facility failed to designate a licensed nurse as charge nurse responsible for supervision of total nursing activities for all shifts, with no charge nurse designated for the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts, potentially affecting all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 23, 2026
Complaint Investigation
Date: Feb 23, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #2739946) at the facility on 02/23/2026 for quality of care, neglect, nursing services, staffing, and environment. The facility was found not in compliance with Medicare and Medicaid requirements and cited F725 due to a separate deficient practice unrelated to the complaint allegations.
Complaint Details
CI MS #2739946 was investigated for quality of care, neglect, nursing services, staffing, and environment. The SA determined the facility was not in compliance and cited F725 due to a separate deficient practice unrelated to the CI allegations.
Findings
F0725 - The facility failed to designate a licensed nurse to serve as the charge nurse for each tour of duty for two of three shifts reviewed (3:00 PM–11:00 PM and 11:00 PM–7:00 AM), potentially affecting all 57 residents.
Deficiencies (1)
F0725 - The facility failed to designate a licensed nurse as charge nurse on the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts, despite policy requiring a charge nurse on each tour of duty.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 16, 2025
Complaint Investigation
Date: Dec 16, 2025
Visit Reason
On 12/16/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 10/02/25. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint survey was reviewed and the facility was found to have corrected the deficient practice; the facility was placed back in compliance.
Findings
The State Agency recommended that the facility be placed back in compliance effective 12/15/25. No deficiencies were cited in this desk review.
Report Facts
Complaint survey date: 1
Inspection Report — Oct 2, 2025
Complaint Investigation
Date: Oct 2, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #2627153, MS #2589164, and MS #481683, at the facility from 10/1/25 through 10/2/25. MS #2627153 was investigated for neglect and misappropriation related to medications and F658 was cited. MS #481683 was investigated related to accidents and F550 and F677 were cited. MS #2589164 was investigated related to Administration/Personnel and there were no citations related to the complaint. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and additionally cited F695.
Complaint Details
Complaint Investigations MS #2627153, MS #2589164, and MS #481683 were conducted. MS #2627153 was for neglect and misappropriation related to medications with deficiency F658 cited. MS #481683 was related to accidents with deficiencies F550 and F677 cited. MS #2589164 was related to Administration/Personnel with no citations. Deficiencies were cited related to the complaints.
Findings
The facility was found not in compliance with multiple requirements including resident rights, medication administration, ADL care, and respiratory care. Deficiencies were cited for failure to ensure privacy during care, improper medication administration practices, unsafe incontinence care methods, and failure to instruct a resident to rinse mouth after inhaled corticosteroid use.
Deficiencies (4)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure a resident’s right to respectful and dignified care when incontinent care was provided without privacy for one of nine sampled residents.
F0658 - Services Provided Meet Professional Standards. The facility failed to ensure medications were administered according to professional standards by not referencing the Medication Administration Record during medication preparation and administration for one of three residents observed.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide personal hygiene and incontinence care in a safe and dignified manner for one of nine sampled residents by providing incontinence care while the resident was suspended in a sit-to-stand lift and failing to shave the resident as required.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to ensure respiratory medications were administered in accordance with manufacturer’s instructions by not instructing a resident to rinse the mouth following administration of an inhaled corticosteroid for one of three medication administrations reviewed.
Report Facts
Deficiencies cited: 4
Inspection Report — Oct 2, 2025
Complaint Investigation
Date: Oct 2, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #2627153, MS #2589164, and MS #481683, at the facility from 10/1/25 through 10/2/25. MS #2627153 was investigated for neglect and misappropriation related to medications and MS #2589164 was investigated related to Administration/Personnel with no citations. MS #481683 was investigated related to accidents and M500 and M610 were cited. During the survey, the facility was found not in compliance with Minimum Standards and cited M655.
Complaint Details
Complaint Investigations MS #2627153 (neglect and misappropriation related to medications) and MS #2589164 (Administration/Personnel) were investigated with no citations. Complaint MS #481683 (accidents) was investigated and deficiencies M500 and M610 were cited.
Findings
The facility was found not in compliance with state licensure requirements, citing three deficiencies related to residents' rights, activities of daily living, and special needs care. Issues included failure to ensure privacy during incontinent care, improper incontinence care techniques, and failure to instruct a resident to rinse mouth after inhaled corticosteroid administration.
Deficiencies (3)
M0500 - Residents' rights were violated when staff provided incontinent care to Resident #1 without ensuring privacy, exposing the resident to his roommate.
M0610 - The facility failed to provide safe and dignified personal hygiene and incontinence care to Resident #1, including improper use of a sit-to-stand lift for incontinence care and failure to shave the resident as needed.
M0655 - The facility failed to ensure respiratory medications were administered properly by not instructing Resident #4 to rinse his mouth after inhaled corticosteroid use.
Report Facts
Deficiencies cited: 3
Inspection Report — Jun 4, 2025
Follow-Up
Date: Jun 4, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 6/4/25 related to an annual recertification survey that was conducted 5/5/25 through 5/8/25.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 5/30/25.
Inspection Report — Jun 4, 2025
Follow-Up
Date: Jun 4, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 6/4/25 related to an annual recertification survey that was conducted 5/5/25 through 5/8/25.
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 5/30/25.
Inspection Report — May 8, 2025
Annual Inspection
Date: May 8, 2025
Visit Reason
The State Agency (SA) conducted an Annual Recertification survey and Complaint Investigation (CI MS #28866) at the facility from 05/05/25 through 05/08/25. The SA investigated MS #28866 for quality of care/treatment related to resident safety with transfers using a mechanical lift and there were no citations regarding the CI. During the annual recertification survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F550, F561, and F584.
Complaint Details
Complaint Investigation (CI MS #28866) was conducted for quality of care/treatment related to resident safety with transfers using a mechanical lift. No citations were issued regarding the complaint.
Findings
The facility was found not in compliance with resident rights, self-determination, and safe/clean/homelike environment requirements. Deficiencies included failure to assist a cognitively impaired resident with smoking breaks and bathing privacy, failure to honor a resident's food preferences, and failure to maintain appropriate hot water temperatures in resident rooms.
Deficiencies (3)
F0550 - Resident Rights/Exercise of Rights. The facility failed to honor a cognitively impaired resident's rights to make choices regarding daily routines by not assisting Resident #25 outdoors for scheduled smoking breaks and failed to ensure privacy during bathing for multiple residents.
F0561 - Self-Determination. The facility failed to honor a resident's food preferences and provide a menu alternative for Resident #30 who did not eat chicken but was repeatedly served it.
F0584 - Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain appropriate and comfortable hot water temperatures in resident rooms on three resident halls, affecting all 57 residents.
Report Facts
Deficiencies cited: 3
Inspection Report — May 8, 2025
Annual Inspection
Date: May 8, 2025
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI), MS #28866 at the facility from 05/05/25 through 05/08/25. The SA investigated MS #28866 for quality of care/treatment related to resident safety during transfers using a mechanical lift and there were no citations related to the CI. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and cited M500 and M955.
Complaint Details
CI MS #28866 investigated quality of care/treatment related to resident safety during transfers using a mechanical lift; no citations were related to the complaint.
Findings
The facility was found not in compliance with state licensure requirements, citing failures to honor residents' rights related to daily preferences, personal routines, and dietary choices, and to maintain appropriate and comfortable water temperatures in resident rooms. No deficiencies were cited related to the complaint investigation.
Deficiencies (2)
M500 - Residents' rights were not fully honored as the facility failed to ensure residents' expressed food preferences were respected, residents were supported in making choices about routines including bathing schedules, and residents were not consistently assisted with scheduled outdoor smoking breaks.
M955 - The facility failed to maintain appropriate and comfortable hot water temperatures in resident rooms on three of three halls, affecting all residents. Observations and interviews confirmed lukewarm or insufficiently hot water in multiple resident bathrooms and sinks, despite repeated complaints and attempts to address the issue.
Report Facts
Deficiencies cited: 2
Inspection Report — May 6, 2025
Life Safety
Date: May 6, 2025
Visit Reason
The State Agency conducted a Life Safety Code survey at the facility on 05/06/2025 to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility failed to provide a hard-wired, remote annunciator panel for the emergency power generator as required by NFPA 110 and NFPA 99. This deficiency affected the entire facility on the day of the survey.
Deficiencies (1)
K0916 - The facility failed to provide a hard-wired, remote annunciator panel for the emergency power generator in a location that is continuously observed by facility staff, which is required by NFPA 110 section 5.6.6 and NFPA 99 section 6.4.1.1.17.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 28, 2025
Complaint Investigation
Date: Jan 28, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27382, at the facility on 1/28/25. CI MS #27382 was investigated for no access to water for residents, residents not groomed, staffing, and infection control.
Complaint Details
CI MS #27382 was investigated for no access to water for residents, residents not groomed, staffing, and infection control. The SA determined the facility was in compliance with no deficiencies cited.
Findings
During the survey, the SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Jan 28, 2025
Complaint Investigation
Date: Jan 28, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #27382, at the facility on 1/28/25. The investigation was for no access to water for residents, residents not groomed, staffing, and infection control.
Complaint Details
CI MS #27382 was investigated for no access to water for residents, residents not groomed, staffing, and infection control. The complaint was not substantiated as no deficiencies were cited.
Findings
The surveyor determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and cited no deficiencies.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 19, 2024
Complaint Investigation
Date: Sep 19, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #26314, MS #26120, and MS #25762, at the facility on 09/18/2024. MS #26314 was investigated related to facility staffing and infection control. MS #26120 was investigated for resident safety/falls and facility staffing. MS #25762 was investigated for infection control.
Complaint Details
Complaint investigations MS #26314, MS #26120, and MS #25762 were conducted related to staffing, infection control, and resident safety/falls. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint investigations: 3
Inspection Report — Sep 19, 2024
Complaint Investigation
Date: Sep 19, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #26314, MS #26120, and MS #25762, related to facility staffing, infection control, and resident safety/falls.
Complaint Details
Complaint Investigations MS #26314, MS #26120, and MS #25762 were investigated for staffing, infection control, and resident safety/falls. The facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint Investigations: 3
Inspection Report — Apr 10, 2024
Complaint Investigation
Date: Apr 10, 2024
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #24045, at the facility on 4/10/24. The complaint was related to waste disposal.
Complaint Details
Complaint CI MS#24045 related to waste disposal was investigated and found to be unsubstantiated; no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Apr 10, 2024
Complaint Investigation
Date: Apr 10, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #24045) related to waste disposal.
Complaint Details
CI MS #24045: Complaint investigation related to waste disposal. The complaint was investigated and no deficiencies were cited.
Findings
The facility was found to be in compliance with the requirements of participation in Medicare and Medicaid, and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 19, 2023
Annual Inspection
Date: Dec 19, 2023
Visit Reason
On 12/19/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 11/02/23. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 12/13/23. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Nov 21, 2023
Complaint Investigation
Date: Nov 21, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #23267 at the facility on 11/21/23 related to Resident Abuse.
Complaint Details
Complaint Investigation CI MS#23267 was related to Resident Abuse and no deficiencies were cited during the survey.
Findings
No deficiencies were cited during this complaint investigation survey; however, the facility remains out of compliance with state licensure requirements due to deficiencies cited on the 11/2/23 licensure survey.
Report Facts
Complaint count: 1
Inspection Report — Nov 2, 2023
Annual Inspection
Date: Nov 2, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/30/2023 through 11/2/2023. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and cited M655.
Findings
The facility failed to provide respiratory care consistent with professional standards as evidenced by the nebulizer mask and oxygen tubing for Resident #40 not being stored in designated plastic bags as required by facility policy.
Deficiencies (1)
M655 - The facility failed to provide respiratory care consistent with professional standards as evidenced by the nebulizer mask and oxygen tubing for Resident #40 not being stored in designated plastic bags as required by facility policy.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 2, 2023
Annual Inspection
Date: Nov 2, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/30/2023 through 11/02/2023. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F656, F679, F695 and F867.
Findings
The facility was found not in compliance with federal requirements in the areas of comprehensive care planning, activities programming, respiratory care, and quality assurance performance improvement. Deficiencies were cited for failure to implement care plan approaches, provide consistent activities, properly store respiratory equipment, and sustain an effective QAPI program.
Deficiencies (4)
F0656 - The facility failed to implement activity care plan approaches for three residents, as scheduled activities were often not conducted and care plans were not consistently followed.
F0679 - The facility failed to provide consistent, structured activities for three residents, with many scheduled activities not occurring and residents reporting boredom and lack of engagement.
F0695 - The facility failed to provide respiratory care consistent with professional standards, as nebulizer masks and oxygen tubing were not stored in designated plastic bags, risking contamination.
F0865 - The facility's Quality Assurance and Performance Improvement (QAPI) program failed to sustain improvements during leadership transitions and did not maintain or monitor corrective actions related to activities programming.
Report Facts
Deficiencies cited: 4
Inspection Report — Oct 31, 2023
Life Safety
Date: Oct 31, 2023
Visit Reason
Survey conducted on 10/31/23 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Aug 23, 2023
Complaint Investigation
Date: Aug 23, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22286, at the facility on 8/23/23 related to accidents/falls.
Complaint Details
Complaint number CI MS#22286 was investigated related to accidents/falls. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Aug 23, 2023
Complaint Investigation
Date: Aug 23, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22286, related to accidents/falls.
Complaint Details
CI MS#22286 was investigated related to accidents/falls. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 3, 2023
Complaint Investigation
Date: Aug 3, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #21966, MS #22001, and MS #22063 at the facility from 8/2/23 through 8/3/23. The SA investigated MS #21966 for pressure sores and falls, MS #22001 for pressure sores, and MS #22063 for neglect and falls.
Complaint Details
Complaint investigations MS #21966, MS #22001, and MS #22063 were conducted for pressure sores, falls, and neglect. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Aug 3, 2023
Complaint Investigation
Date: Aug 3, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #21966, MS #22001, and MS #22063 at the facility from 8/2/23 through 8/3/23. The SA investigated MS #21966 for pressure sores and falls, MS #22001 for pressure sores, and MS #22063 for neglect and falls.
Complaint Details
Complaint Investigations MS #21966, MS #22001, and MS #22063 were conducted for pressure sores, falls, and neglect. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid. There were no deficiencies cited.
Inspection Report — Feb 9, 2023
Complaint Investigation
Date: Feb 9, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #20618, at the facility on 2/9/2023 related to resident not groomed adequately, misappropriation, and resident assessment.
Complaint Details
Complaint MS #20618 involved allegations of resident not groomed adequately, misappropriation, and resident assessment. The complaint was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The surveyor determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Feb 9, 2023
Complaint Investigation
Date: Feb 9, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #20618 at the facility on 2/9/2023. MS #20618 was related to resident not groomed adequately, misappropriation, and resident assessment.
Complaint Details
Complaint MS #20618 involved allegations of resident not groomed adequately, misappropriation, and resident assessment. The complaint was investigated and no deficiencies were cited.
Findings
The facility was found to be in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint number: 20618
Inspection Report — Dec 13, 2022
Complaint Investigation
Date: Dec 13, 2022
Visit Reason
On 12/13/22 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 11/8/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Complaint Details
Complaint survey completed on 11/8/22; the facility was found to have corrected the deficient practice and sustained compliance.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 12/2/22. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Nov 8, 2022
Complaint Investigation
Date: Nov 8, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19759, at the facility on 11/08/22.
Complaint Details
Complaint number CI MS#19759 was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement.
Inspection Report — Nov 8, 2022
Complaint Investigation
Date: Nov 8, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19759 at the facility on 11/08/22. During the survey, the SA substantiated MS #19759 related to catheter care and determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid.
Complaint Details
CI MS#19759 related to catheter care was substantiated with deficiencies cited.
Findings
F0690 - The facility failed to change a resident's suprapubic catheter as needed for leakage for one of two residents reviewed with indwelling catheters, causing discomfort and odor in the resident's room.
Deficiencies (1)
F0690 - The facility failed to change a resident's suprapubic catheter as needed for leakage, resulting in discomfort and odor for the resident.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 23, 2021
Follow-Up
Date: Nov 23, 2021
Visit Reason
The State Agency (SA) conducted a follow up/revisit survey at the facility on 11/23/21 for complaint investigation (CI) MS #18150, CI MS #18021, CI MS #18134, CI MS #18058, and an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) from 10/4/21 through 10/16/21.
Complaint Details
Follow up survey for complaint investigations CI MS #18150, CI MS #18021, CI MS #18134, CI MS #18058, and Immediate Jeopardy and Substandard Quality of Care from 10/4/21 through 10/16/21. The facility was found in compliance.
Findings
The facility was in compliance with the Mississippi Regulations for Minimum Standards of for Institutions for the Aged or Infirm.
Inspection Report — Nov 23, 2021
Follow-Up
Date: Nov 23, 2021
Visit Reason
The State Agency conducted a follow up/revisit survey at the facility on 11/23/21 for complaint investigation (CI) MS #18150, CI MS #18021, CI MS #18134, CI MS #18058, and an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) from 10/4/21 through 10/16/21.
Complaint Details
Complaint investigations CI MS #18150, CI MS #18021, CI MS #18134, CI MS #18058, and Immediate Jeopardy and Substandard Quality of Care from 10/4/21 through 10/16/21 were reviewed; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency determined the facility was in compliance with the requirements of participation in Medicare and Medicaid.
Report Facts
Complaint investigations: 5
Inspection Report — Oct 8, 2021
Complaint Investigation
Date: Oct 8, 2021
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI) MS #18150, CI MS #18021, CI MS #18134, and CI MS #18058 at the facility from 10/4/21 through 10/16/21. The SA substantiated CI MS #18058 for nutritional supplement not provided on meal trays and not providing feeding assistance for a resident with weight loss and a high risk for aspiration.
Complaint Details
CI MS #18058 was substantiated for nutritional supplement not provided on meal trays and not providing feeding assistance for a resident with weight loss and a high risk for aspiration. Other complaints CI MS #18150 and CI MS #18134 were substantiated with citations for resident rights but no deficiencies cited. CI MS #18021 was not substantiated.
Findings
The facility was found not in substantial compliance with Medicare and Medicaid requirements. Deficiencies were cited for failure to provide scheduled showers per resident preference, failure to develop and implement comprehensive care plans for aspiration risk and weight loss, and failure to provide adequate nutrition and hydration including delayed enteral feeding orders.
Deficiencies (4)
F0550 - Resident Rights/Exercise of Rights. The facility failed to provide scheduled showers per resident preference at least three times a week for one resident, who reported receiving only bed baths and not preferred gurney showers.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement a comprehensive care plan for a resident with high risk of aspiration, failed to obtain timely orders for enteral feedings after feeding tube placement, and failed to provide feeding assistance, placing the resident at risk of serious harm.
F0657 - Care Plan Timing and Revision. The facility failed to revise the comprehensive care plan from potential to actual weight loss for a resident with severe weight loss and aspiration risk, resulting in inadequate care and monitoring.
F0692 - Nutrition/Hydration Status Maintenance. The facility failed to ensure a nutritional supplement was included on a meal tray, failed to follow recommendations from a barium swallow study for a resident at high risk for aspiration, and failed to obtain timely orders for enteral feedings after feeding tube placement, placing the resident and others at risk of serious harm.
Report Facts
Deficiencies cited: 4
Licensed beds: 60
Weight loss: 7.58
Weight loss: 17.51
Weight loss: 10.8
Meal consumption: 40
Meal consumption: 25
Meal consumption: 75
Meal consumption: 50
Tags cited: 4
Inspection Report — Mar 11, 2021
Date: Mar 11, 2021
Visit Reason
A desk review was conducted on 3/11/21.
Findings
The facility was found to be in substantial compliance as of 3/11/21.
Inspection Report — Feb 19, 2021
Life Safety
Date: Feb 19, 2021
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility met the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Feb 19, 2021
Routine
Date: Feb 19, 2021
Visit Reason
Survey conducted on 02/19/21 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Feb 11, 2021
Annual Inspection
Date: Feb 11, 2021
Visit Reason
The State Agency (SA) conducted an annual survey from 2/08/21 through 2/11/21. During the survey the SA determined the facility was not in compliance with the Medicare and Medicaid Requirements for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in resident rights, activities programming, and infection control.
Deficiencies (3)
F0550 - Resident Rights/Exercise of Rights. The facility failed to honor residents' rights by not allowing three of five residents reviewed to smoke due to COVID-19 quarantine restrictions.
F0679 - Activities Meet Interest/Needs Each Resident. The facility failed to provide an ongoing activities program for five of fourteen sampled residents, with limited documented activities and residents reporting boredom and social isolation due to COVID-19 restrictions.
F0880 - Infection Prevention & Control. The facility failed to follow standard infection control precautions during wound care for two residents, including failure to remove soiled gloves and perform hand hygiene before applying clean dressings.
Report Facts
Deficiencies cited: 3
Inspection Report — Sep 21, 2020
Routine
Date: Sep 21, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 9/21/2020. Additionally, a complaint investigation (CI MS #17029) was conducted on the same date.
Complaint Details
CI MS #17029 - The complaint investigation was unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with infection control regulations and Medicare and Medicaid requirements. No deficiencies were cited during the complaint investigation.
Report Facts
Deficiencies cited: 0
Inspection Report — May 25, 2020
Routine
Date: May 25, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/25/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Feb 16, 2020
Complaint Investigation
Date: Feb 16, 2020
Visit Reason
The State Agency conducted a complaint survey, MS #16586 at the facility on 02/16/2020. The SA substantiated the allegation for abuse related to reporting in a timely manner and cited F609. The SA did not substantiate MS #16586 for Quality of Care related to incontinent care.
Complaint Details
Complaint MS #16586 involved an allegation of abuse related to timely reporting. The allegation was substantiated and deficiencies were cited.
Findings
The facility was found not in compliance due to failure to report an allegation of abuse to the appropriate State agencies within the required two-hour time frame for one resident.
Deficiencies (1)
F0609 - Reporting of Alleged Violations. The facility failed to report an allegation of abuse to the appropriate State agencies within the required two-hour time frame for one of five residents reviewed.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 14, 2019
Complaint Investigation
Date: Nov 14, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation on 11/14/19.
Complaint Details
CI MS #16362: Complaint investigation for abuse was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated for abuse with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 20, 2019
Complaint Investigation
Date: Aug 20, 2019
Visit Reason
The State Agency conducted complaint surveys at the facility from 8/19/2019 to 8/20/2019 for two complaints: Dehydration and Fall with Injury.
Complaint Details
CI MS #15971: Complaint for Dehydration was not substantiated and no deficiencies were cited. CI MS #16074: Complaint for Fall with Injury was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited for either complaint.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 12, 2019
Annual Inspection
Date: Feb 12, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey from 02/10/19 through 02/12/19. During the survey, the SA determined the facility was not in compliance with the Medicare and Medicaid Requirements for participation.
Findings
The facility was found not in compliance due to failure to ensure residents had access to survey results. The facility failed to post or make survey results accessible to residents and visitors.
Deficiencies (1)
F0577 - Right to Survey Results/Advocate Agency Info. The facility failed to ensure residents had access to survey results for all 55 residents as survey results were not posted or accessible in the facility.
Report Facts
Deficiencies cited: 1
4 CMS Surveys
Inspection Report — Oct 2, 2025
Annual Inspection
Date: Oct 2, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility on 10/02/2025.
Findings
The facility was found to have deficiencies in providing dignified care, medication administration, activities of daily living assistance, and respiratory care. Four deficiencies were cited related to privacy during care, medication administration without referencing MAR, improper incontinence care technique, and failure to instruct mouth rinsing after inhaled corticosteroid use.
Deficiencies (4)
F0550 - The facility failed to ensure a resident's right to dignified care by not providing privacy during incontinence care for Resident #1.
F0658 - The facility failed to ensure medications were administered according to professional standards by not referencing the MAR during medication administration for Resident #8.
F0677 - The facility failed to provide safe and dignified assistance with activities of daily living by providing incontinence care while Resident #1 was suspended in a sit-to-stand lift and not shaving the resident as required.
F0695 - The facility failed to provide safe respiratory care by not instructing Resident #4 to rinse his mouth after administration of an inhaled corticosteroid.
Report Facts
Deficiencies cited: 4
Inspection Report — May 8, 2025
Annual Inspection
Date: May 8, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 05/05/2025 through 05/08/2025.
Findings
The facility was found to have multiple deficiencies including failure to honor residents' rights regarding smoking breaks and bathing schedules, failure to accommodate food preferences, and failure to maintain appropriate hot water temperatures in resident rooms. These issues affected multiple residents and were documented through observations, interviews, and record reviews.
Deficiencies (3)
F0550 - Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. The facility failed to assist a cognitively impaired resident with scheduled smoking breaks and failed to accommodate residents' bathing time preferences and privacy, affecting 11 of 57 residents.
F0561 - Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. The facility failed to honor a resident's food preferences and provide a menu alternative for one of sixteen sampled residents.
F0584 - Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility failed to maintain appropriate and comfortable hot water temperatures in resident rooms on three resident halls, affecting all 57 residents.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 2, 2023
Annual Inspection
Date: Nov 2, 2023
Visit Reason
The State Agency conducted an annual recertification survey at the facility on 11/02/2023.
Findings
The facility was found to have deficiencies in providing consistent activities for residents, respiratory care storage practices, and sustaining an effective QAPI program. Three residents were affected by lack of structured activities, respiratory equipment was not stored properly, and the QAPI committee failed to maintain improvements from prior surveys.
Deficiencies (4)
F0656 - Develop and implement a complete care plan that meets all the resident's needs, with measurable actions. The facility failed to implement activity care plan approaches for three sampled residents.
F0679 - Provide activities to meet all resident's needs. The facility failed to provide structured activities for three sampled residents, with scheduled activities often not conducted and residents left with nothing to do.
F0695 - Provide safe and appropriate respiratory care for a resident when needed. The facility failed to store nebulizer masks and oxygen tubing in designated plastic bags to prevent contamination.
F0865 - Have a plan that describes the process for conducting QAPI and QAA activities. The facility's QAPI Committee failed to sustain the program during leadership transitions and did not monitor or maintain corrective actions related to resident activities.
Report Facts
Deficiencies cited: 4
Inspection Report — Feb 11, 2021
Annual Inspection
Date: Feb 11, 2021
Visit Reason
The State Agency conducted an annual recertification survey at the facility. The survey included review of resident rights, activities, and infection control practices during the COVID-19 pandemic.
Findings
The facility failed to honor residents' rights by not allowing them to smoke due to COVID-19 quarantine restrictions. The facility also failed to provide an ongoing activities program for several residents, resulting in social isolation and boredom. Additionally, infection control practices were not properly followed during wound care, risking possible infection.
Deficiencies (3)
F0550 - Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. The facility failed to allow residents to smoke due to COVID-19 quarantine despite nicotine replacement therapy being offered.
F0679 - Provide activities to meet all resident's needs. The facility failed to provide an ongoing activities program for five of fourteen sampled residents, resulting in social isolation and lack of engagement.
F0880 - Provide and implement an infection prevention and control program. The facility failed to follow standard infection control precautions during wound care for two residents by not changing gloves and performing hand hygiene, risking wound contamination.
Report Facts
Deficiencies cited: 3
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