Inspection Reports for
Pine Forest Health and Rehabilitation

Complaint survey completed 08/19/26 found the facility out of compliance with Medicare and Medicaid participation requirements.

The facility was found to have corrected prior deficiencies from the 07/16/26 survey but remained out of compliance with Medicare and Medicaid participation requirements based on the complaint survey completed 08/19/26.

The facility was found to have corrected prior deficiencies from the July complaint survey but remained out of compliance with Minimum Standards related to a complaint survey completed on 08/19/26.

Two complaint investigations were conducted: CI MS #3117793 related to quality of care/treatment, accidents/fall, and residents’ rights with deficiency F657 cited; and CI MS #3152582 regarding administration, residents’ rights, and neglect with deficiencies F553 and F573 cited.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies in resident participation in care planning, access to medical records, and updating care plans after falls.

CI MS #3117793 was investigated related to quality of care/treatment, accidents/fall, and residents’ rights and F657 was cited. CI MS #3152582 was investigated regarding administration, residents’ rights and neglect and F553 and F573 were cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements; no deficiencies were cited in this report.

Three complaint investigations were conducted: CI MS# 3053430 regarding accidents, quality of care and neglect; CI MS# 3055083 regarding physical environment with deficiencies cited; and CI MS# 3093491 regarding accidents/incidents with no deficiencies cited.

Two deficiencies were cited related to the facility's failure to ensure call lights were within reach for two residents and failure to maintain a safe, functional, and comfortable kitchen environment due to a malfunctioning air-conditioning system.

Three complaint investigations were conducted: CI MS# 3053430 (accidents, quality of care and neglect), CI MS# 3055083 (physical environment), and CI MS# 3093491 (accidents/incidents). Deficiency was cited only for CI MS# 3055083 related to physical environment; no deficiencies were cited for the other two complaints.

The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm related to CI MS# 3055083. The facility failed to ensure call lights were within reach for two residents, Resident #1 and Resident #2, as the call light devices were found on the floor and inaccessible to them.

Complaint survey conducted on 5/26/26 through 5/28/26; the facility was found in compliance with no deficiencies cited.

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 6/19/26.

Complaint survey conducted on 5/26/26 through 5/28/26; the follow-up revisit found the facility in compliance and no deficiencies were cited.

The State Agency found the facility to be in compliance with the requirements of the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and recommends the facility be placed back in compliance effective 6/19/26.

Two complaint investigations were conducted: CI MS #3030803 for neglect and nursing services, and CI MS #3043552 for physical environment. Both complaints were investigated and the facility was found in compliance with no deficiencies cited.

The State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint investigations CI MS #3030803 and CI MS #3043552 were conducted related to neglect, nursing services, and physical environment. The facility was found in compliance with no deficiencies cited.

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.

Eight Complaint Investigations (CI MS #3020262, CI MS #3007186, CI MS #2985189, CI MS #2985198, CI MS #2981857, CI MS #2981883, CI MS #2981968, and CI MS #2982038) were conducted. The facility was cited for F880 related to CI MS# 3007186 involving Activities of Daily Living care.

The facility failed to prevent the possibility of spreading infection during Activities of Daily Living care for one resident, due to improper hand hygiene and glove use by a Certified Nursing Assistant. This failure placed the resident at risk for infections and skin damage.

Eight complaint investigations were conducted (CI MS #3020262, #3007186, #2985189, #2985198, #2981857, #2981883, #2981968, and #2982038) covering abuse, nursing services, misappropriation of funds, ADL care, and trust fund services. Deficiency M1570 was cited indicating non-compliance.

The facility failed to prevent the possibility of spreading infection during Activities of Daily Living care for one resident. Certified Nursing Assistant #1 did not perform proper hand hygiene before, during, and after care, placing the resident at risk for infections and skin damage.

Complaint Investigation CI MS#2961494, CI MS#2806719, CI MS#2874513, CI MS#2968243, CI MS#2966163, and CI MS#2964901 were investigated covering resident rights, quality of care, death in facility and neglect, infection control, nursing services, administration, call lights, and accidents/elopement. The facility was found in compliance with no deficiencies cited.

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.

Complaint Investigation CI MS#2961494, 2806719, 2874513, 2968243, 2966163, and 2964901 were investigated covering resident rights, quality of care, death in facility and neglect, infection control, nursing services, administration, call lights, and accidents/elopement. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

The facility was found to have corrected the deficiencies from the 12/09/25 survey but remained out of compliance due to deficiencies cited on the 01/08/26 survey. The SA recommends the facility be placed back in compliance effective 1/30/26.

The facility remained out of compliance with the Mississippi State Licensure Regulations due to deficiencies cited on the 01/08/26 survey. The SA recommends the facility be placed back in compliance effective 1/30/26.

CI MS #2730892 related to quality of care; the complaint was investigated and no deficiencies were cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm; no deficiencies were cited.

The complaint investigation found that the facility did not notify Resident #1's Resident Representative of the fall until the next day and failed to conduct required assessments and monitoring following the fall. The Resident Representative was upset about the delayed notification and lack of timely care.

The facility failed to notify the Resident Representative of a fall experienced by Resident #1 on 12/27/25 until the following morning. The facility also failed to perform timely assessments, neuro-checks, and vital sign monitoring as required by policy. The resident was transported to an emergency department for evaluation after the fall. The facility initiated in-service training following the incident.

Complaint #2704746 was investigated related to accidents and resident rights. Deficiencies were cited for failure to notify the resident representative and failure to assess and evaluate injury after a fall. The complaint was substantiated.

Two deficiencies were cited related to failure to notify the resident representative of a fall and failure to evaluate and assess potential injury after the fall. The facility failed to notify the resident representative of Resident #1's fall on 12/27/25 until the next day and did not perform timely neurological checks or vital sign monitoring as required.

CI MS#2662480 was a facility reported incident related to an accident. The SA determined the facility was not in compliance and cited F0689.

F0689 - The facility failed to ensure the resident environment was free of accident hazards by not securing a wheelchair during van loading, resulting in a fall that caused scapular and multiple rib fractures to one resident.

The investigation was complaint-related, involving a fall of Resident #1 during transport due to failure to lock wheelchair wheels. The fall was substantiated, resulting in actual harm with fractures.

The facility failed to ensure the resident environment was free from accident hazards by not properly securing a wheelchair during van loading, resulting in a resident sustaining a scapular fracture and multiple rib fractures. The investigation confirmed that a Certified Nurse Aide failed to lock both wheelchair wheels, causing the resident to fall from the van lift platform.

Complaint survey completed on 09/04/25; the facility was found to have corrected the deficiencies and was placed back in compliance effective 10/07/25.

The facility was found to be back in compliance effective 10/07/25. No deficiencies were cited in this desk review.

Complaint Investigation (CI), MS #2605687 was investigated relating to activities and bowel and bladder. CI MS #2573510 was investigated relating to private sitting services. Deficiencies were cited related to CI MS #2605687.

The facility was found not in compliance with requirements related to care planning and activities for two residents. Deficiencies were cited for failure to implement care plans and provide activities meeting residents' interests and needs.

The facility failed to implement care plans related to participation in structured activities for two residents. Observations and interviews confirmed residents were not engaged in appropriate activities, and staff did not follow care plans, resulting in minimal harm or potential for actual harm.

Complaint Investigation (CI), MS #2605687 and CI MS #2573510 were conducted. CI MS #2605687 related to activities and bowel and bladder, and CI MS #2573510 related to private sitting services. Deficiency M0780 was cited related to CI MS #2605687.

The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, citing M0780 for failure to provide suitable recreational and entertainment activities meeting residents' physical and mental needs for two residents reviewed.

The State Agency found the facility to be 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 7/4/25.

The facility was found to be in compliance with the requirements of participation in Medicare and Medicaid and is recommended to be placed back in compliance effective 7/4/25.

CI MS#29394 was investigated related to allegations of abuse and neglect. No deficiencies were cited related to this complaint investigation.

No deficiencies were cited related to the complaint investigation; however, the facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on the 06/06/25 survey.

CI MS#29394 was investigated related to allegations of abuse and neglect. No deficiencies were cited related to this complaint.

No deficiencies were cited related to the complaint investigation. The facility remains out of compliance due to deficiencies cited on the 06/06/25 survey.

The State Agency confirmed the facility was in compliance with the Life Safety Code and recommended the facility be placed back in compliance effective 06/04/25.

The complaint investigation substantiated failures in care planning for two residents, inadequate supervision leading to a resident eloping and being found in a hazardous public area, and improper incontinent care for one resident. Immediate jeopardy was identified related to the elopement incident but was removed after corrective actions were implemented.

The facility failed to implement comprehensive care plans for two residents, failed to provide adequate supervision resulting in a resident eloping and being found in a dangerous situation, and failed to provide appropriate incontinent care for one resident, placing residents at risk of harm or infection.

Four complaint investigations were conducted (CI MS #28868, CI MS #28989, CI MS #29026, and CI MS #29005). No citations were issued for the first three complaints. For CI MS #29005, related to falls, resident safety, and quality of care/treatment, deficiencies F656 and F689 were cited. The complaint was substantiated with deficiencies cited.

The facility was found not in compliance with Medicare and Medicaid participation requirements, with Immediate Jeopardy identified related to resident elopement and substandard quality of care. Deficiencies were cited for failure to develop and implement comprehensive care plans, failure to provide adequate supervision to prevent accidents, and failure to provide appropriate incontinent care.

Complaint Investigations CI MS# 28868, CI MS# 28989, CI MS# 29026, and CI MS# 29005 were investigated. Deficiencies were cited related to wound care, incontinence care, and accident prevention. Immediate Jeopardy was identified due to Resident #211 eloping and was removed after corrective actions.

The facility was cited for multiple deficiencies including failure to provide proper wound care and incontinence care for Resident #98, and failure to provide adequate supervision and risk assessment to prevent Resident #211 from eloping, which placed the resident in Immediate Jeopardy. The facility implemented corrective actions and removal plans, which were validated by the State Agency.

The complaint investigation was triggered by Resident #211 eloping from the facility unsupervised on 06/04/2025, resulting in immediate jeopardy. The resident was found sitting on a trailer in a busy intersection. The investigation included interviews, observations, and record reviews related to the elopement, care plan implementation, infection control, and quality assurance.

The facility failed to protect a resident from elopement resulting in immediate jeopardy, failed to implement comprehensive care plans for residents, and did not follow infection prevention protocols. The facility also showed deficiencies in quality assurance and performance improvement processes.

The facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on a subsequent complaint survey. No specific deficiencies are cited in this document.

The facility was found to remain out of compliance with Medicare and Medicaid requirements due to deficiencies cited in a subsequent complaint survey. Measures had been put in place to correct prior deficient practices effective 2/28/25.

The complaint investigation was triggered by an allegation from Resident #1 that CNA #1 physically abused him during care on 1/9/2025. The resident had bruising and hematoma on his face and head. Multiple staff and resident interviews, record reviews, and hospital documentation were conducted. The facility's internal investigation concluded the allegation was not substantiated because Resident #1 was the aggressor and staff was attempting to prevent harm. The CNA was sent home pending investigation and had not returned to work due to injury from the resident biting her finger.

The facility failed to ensure Resident #1's right to be free from physical abuse when CNA #1 admitted to using physical force on the resident's left arm and face during care. The resident had bruising and hematoma consistent with the incident. The facility's investigation concluded the abuse allegation was not substantiated as the resident was the aggressor. Additionally, the facility failed to implement comprehensive care plan interventions regarding the resident's behavior during care.

Three complaint investigations were conducted (CI MS #27918, CI MS #27967, and CI MS #27939). CI MS #27967 had no citations. CI MS #27939 was related to employee to resident abuse, resident safety, and resident rights. CI MS #27918 was related to physical abuse and resident safety and resulted in citations for F600 and F656.

The facility was found not in compliance with requirements of participation in Medicare and Medicaid due to failure to prevent physical abuse and failure to implement comprehensive care plan interventions. Resident #1 was physically abused by CNA #1 during care, resulting in bruising and hematoma. The facility's investigation concluded the resident was the aggressor but staff failed to follow the care plan to stop care when the resident became agitated.

The investigation was complaint-driven, focusing on issues raised by residents and families regarding call light accessibility, grievance handling, and a fall incident involving a mechanical lift. The grievances were found to be inadequately addressed and documented by the facility.

The facility failed to ensure call lights were within reach for some residents, did not adequately acknowledge or resolve grievances from residents and families, and failed to provide adequate supervision during a mechanical lift transfer resulting in a resident injury.

Five complaint investigations were conducted (CI MS #27324, CI MS #27388, CI MS #27404, CI MS #27635, and CI MS #27658). Deficiencies were cited related to neglect and quality of care (F558), physical environment and grievances (F585), and accidents/falls and equipment maintenance (F689). No deficiencies were cited for CI MS #27635 or CI MS #27658.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to reasonable accommodations, grievance handling, and accident hazards including a resident fall with injury.

Complaint Investigation MS #26744 and MS #26745 involved quality of care/treatment and injury of unknown origin. The complaints were investigated and found to be unsubstantiated with no deficiencies cited.

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.

Complaint Investigation MS #26744 and MS #26745 regarding quality of care/treatment and injury of unknown origin; administration and quality of care/treatment and injury of unknown origin. The facility was found in compliance with no deficiencies cited.

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

Complaint number CI MS #26606 was investigated related to a resident elopement. The SA determined the facility was in compliance with no deficiencies cited.

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.

CI MS #26606 was investigated related to a resident elopement. The SA determined the facility was in compliance with no deficiencies cited.

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

CI MS#26995 - The complaint investigation was substantiated as the facility implemented corrective measures and was placed back in compliance effective 08/22/24.

The facility was found to be in compliance with Medicare and Medicaid requirements as of 08/22/24, with no deficiencies cited.

Complaint Investigation MS #26021 was related to Quality of Care and Resident Neglect. No deficiencies were cited during this investigation.

No deficiencies were cited during this survey, but the facility remains out of compliance with state licensure requirements due to deficiencies cited on the 07/18/24 survey.

Complaint CI MS#26021 was investigated related to Quality of Care and Resident Neglect. No deficiencies were cited during this investigation.

No deficiencies were cited during this survey. The facility remains out of compliance due to deficiencies cited on the 07/18/24 survey.

The complaint investigation from 7/15/24 to 7/18/24 substantiated failures in implementing comprehensive care plans for ADL care and grooming. The facility had prior similar deficiencies cited in December 2023, indicating ongoing issues.

The facility failed to provide adequate ADL care including fingernail and toenail grooming and removal of unwanted facial hair for four of seven sampled residents. The Quality Assurance and Performance Improvement (QAPI) committee also failed to sustain effective oversight to prevent recurrence of these deficiencies.

The complaint investigations included multiple complaint numbers (CI MS #25800, #25804, #25784, #25345, #25245, #25244, #25614, #25836, #25890, and #25894) related to neglect, quality of care, physical environment, resident rights, misappropriation of property, injury of unknown origin, insufficient supplies, call light response, rehabilitation services, nursing services, and allegations of neglect. Deficiencies were cited related to CI MS #25784 and CI MS #25245.

The facility was found not in compliance with Medicare and Medicaid participation requirements and cited for failure to implement individualized comprehensive care plans for ADL care and failure to provide necessary grooming services including nail care and removal of unwanted facial hair for dependent residents. The facility also failed to sustain an effective QAPI program, resulting in re-cited deficiencies from the prior survey.

Complaint Investigation CI MS#24616 and MS#24141 investigated Admission, Transfer and Discharge Rights, and Resident Neglect and Quality of Care related to resident left wet for extended periods. The complaints were not substantiated; no deficiencies were cited.

The survey 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.

Complaint Investigation MS #24616 related to Admission, Transfer and Discharge Rights and MS #24141 related to Resident Neglect and Quality of Care were investigated and found to be unsubstantiated with no deficiencies cited.

The surveyor determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint Investigations (CI), MS #23421 and MS #23434 were conducted from 11/27/23 through 12/5/23. The facility was found in compliance with no deficiencies cited.

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 1/2/24.

Complaint Investigations CI MS #23421 and CI MS #23434 were investigated and the facility was found in compliance with no deficiencies cited.

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 1/2/24.

The facility was found to be in compliance with the Life Safety Code as the State Agency recommended the facility be placed back in compliance effective 01/02/24.

The State Agency is recommending that the facility be placed back in compliance effective 01/02/24. No deficiencies were cited in this desk review.

Complaint Investigations MS #23421 and MS #23434 related to Pressure Ulcer care were substantiated with deficiencies cited.

The facility was found not in compliance with requirements for participation in Medicare and Medicaid, citing multiple deficiencies including failure to provide adequate pressure ulcer care, failure to honor resident self-determination, and infection control issues. Immediate Jeopardy was identified and removed during the survey.

The facility was cited for multiple deficiencies including failure to honor resident self-determination, failure to prevent neglect and abuse, inadequate comprehensive care plans especially related to pressure ulcers, failure to provide appropriate pressure ulcer care and documentation, failure to maintain resident hygiene and grooming, failure to provide appropriate range of motion care, failure to ensure staff competency in wound care, failure to accommodate resident food preferences, and failure to implement infection prevention and control measures including proper PPE use and catheter care. Immediate Jeopardy was identified related to pressure ulcer care and comprehensive care planning but was removed after corrective actions.

The facility failed to provide the required annual inspection of the fire sprinkler system for the current year 2023; the last documented inspection was on 2/8/2022. This finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview.

Complaint Investigation MS #22717 and MS #22767 regarding pressure sores, inadequate grooming, inappropriate feeding assistance, and Administration. The facility was found in compliance with no deficiencies cited.

The survey 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.

Complaint Investigations CI MS #22717 and CI MS #22767 were conducted regarding pressure sores, inadequate grooming, inappropriate feeding assistance, and Administration. The facility was found in compliance with no deficiencies cited.

The State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint number CI MS#22667 was investigated related to physical environment and quality of care. The complaint was not substantiated as no deficiencies were cited.

The facility was found in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint number CI MS#22667 was investigated related to physical environment and quality of care. The SA determined the facility was in compliance with no deficiencies cited.

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.

Complaint number CI MS#22330 was investigated related to resident abuse. The SA determined the facility was in compliance with no deficiencies cited.

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.

Complaint number CI MS#22330 was investigated related to abuse. The SA determined the facility was in compliance with no deficiencies cited.

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

Complaint numbers MS #19483 and MS #19602 were investigated. MS #19483 related to Quality of Care/Treatment including staffing, feeding assistance, medications, grooming, water, rehabilitation services and misappropriation of property. MS #19602 related to Resident Abuse. Both complaints were not substantiated and no deficiencies were cited.

The SA determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.

Complaint numbers MS #19483 and MS #19602 were investigated; MS #19483 involved Quality of Care/Treatment related to staffing, feeding assistance, medications, grooming, water, rehabilitation services and misappropriation of property, and MS #19602 involved Resident Abuse. Both complaints were not substantiated and no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited related to the complaints investigated.

CI MS#18261 was substantiated related to an elopement incident on 10/19/21 when the facility failed to provide supervision to prevent Resident #1 from leaving the facility unsupervised. The complaint investigation found Immediate Jeopardy which was removed on 10/22/21.

F0689 was cited for failure to provide adequate supervision to prevent Resident #1's elopement on 10/19/21. Resident #1 exited the facility through a window unnoticed and was found approximately 125 feet away. The facility implemented corrective actions including 1:1 supervision, staff in-services, window stops, and elopement drills. The Immediate Jeopardy was removed on 10/22/21 and the deficiency was determined to be past non-compliance.

Five complaint investigations were conducted (CI MS #17199, CI MS #17230, CI MS #17351, CI MS #17367, and CI MS #17594). None were substantiated and no citations were related to the complaints.

The facility was found not in compliance with Medicare and Medicaid participation requirements. The SA did not substantiate any of the five complaint investigations but cited nine deficiencies during the survey.

The survey included five complaint investigations (CI MS #17199, CI MS #17230, CI MS #17351, CI MS #17367, and CI MS #17594). None of these complaints were substantiated or resulted in citations.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to resident self-determination, grievances, safekeeping of resident belongings, reporting of crimes and alleged violations, ADL care, accident hazards, medication errors, infection control, and environmental safety.

The investigation was complaint-driven, focusing on issues such as resident food preferences, missing belongings, suspected drug use by staff, failure to report crimes, inadequate ADL care, supervision failures, medication errors, infection control lapses, and unsafe equipment conditions.

The facility was found deficient in honoring resident food preferences, maintaining safekeeping of resident belongings, timely reporting of suspected crimes, providing adequate activities of daily living care, supervising residents to prevent accidents, ensuring medication administration accuracy, infection prevention and control, and maintaining safe equipment.

The facility failed to provide a one half-hour fire resistance rating in smoke barrier walls in three smoke compartments, affecting 48 of 68 residents. The unsealed openings around sprinkler pipe penetrations near rooms 101, 201, and 301 were observed and acknowledged by facility leadership.

The facility was found not to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

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

CI MS #16667 was investigated from 08/31/2020 through 09/01/2020. Deficiencies were cited at F0656 and F0657.

The facility was cited for deficiencies at F0656 and F0657 during the complaint investigation.

The facility was found to be in compliance with 42 CFR 438.80 infection control regulations and has implemented the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

No new observations related to infection control were noted during this survey; however, the facility remains out of compliance based on deficiencies cited during the October 15, 2020 survey.

The facility was found to be in compliance with infection control regulations during the COVID-19 focused infection control survey.

Complaint Investigation (CI) MS #16667 was conducted from 08/31/2020 through 09/01/2020. Deficiencies were cited at F656 and F657.

The facility was cited for two deficiencies related to comprehensive care plans. The facility failed to implement interventions to help prevent infections on catheter care plans for two residents and failed to update and revise resident care plans with current physician's orders for Foley catheter care for two residents.

The facility was found to be in compliance with 42 CFR 438.80 infection control regulations and has implemented the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

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

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.

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.

Complaint investigation CI MS #16479 & CI MS #16625 was unsubstantiated with no deficiencies cited.

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

Complaint MS#16358 involved quality of care/treatment and Fall with Fracture; complaint MS#16392 involved quality of care and neglect of Resident #1 including neglect, failure to provide water, falls, and failure to provide incontinent care. Both complaints were not substantiated and no deficiencies were cited.

The concerns related to both complaints were not substantiated, and no deficiencies were cited. The facility was determined to be in substantial compliance with Medicare and Medicaid requirements.

Complaint investigation CI MS #15717, CI MS #15970 & CI MS #16068 was unsubstantiated with no deficiencies cited.

The investigation was unsubstantiated with no deficiencies cited.

The survey identified multiple deficiencies including issues with resident care plans, infection control, catheter care, oxygen use, food safety, and emergency preparedness. The facility failed to ensure appropriate briefs for incontinent residents, failed to remove unnecessary isolation precautions, and did not provide timely written notices for resident transfers. Several care plans were incomplete or not updated, and infection control practices were not consistently followed.