Inspection Reports for
Pine Forest Health and Rehabilitation
1116 Forest Avenue, Jackson, MS, 39206
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 8, 2026
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's representative of a fall and to properly assess and evaluate the resident after the fall.
Complaint Details
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.
Findings
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.
Deficiencies (2)
F 0580: The facility failed to notify the Resident Representative of a change in condition for Resident #1 after a fall on 12/27/25 until 12/28/25 morning.
F 0689: The facility failed to evaluate, assess, and identify potential injury for Resident #1 after a fall on 12/27/25, including failure to perform neuro-checks and vital sign monitoring during the night shifts following the fall.
Report Facts
Date of fall: Dec 27, 2025
Date of notification to Resident Representative: Dec 28, 2025
Brief Interview for Mental Status (BIMS) score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | CNA | Provided written statement about responding to Resident #1's fall |
| Unit Manager | Interviewed regarding notification and assessment after Resident #1's fall | |
| Director of Nursing | DON | Interviewed about notification and investigation of Resident #1's fall |
| Certified Nursing Assistant #1 | CNA | Observed Resident #1 on floor after fall and assisted in care |
| Licensed Practical Nurse #1 | LPN | Instructed CNAs to assist Resident #1 after fall |
| Nurse Practitioner #1 | Primary Healthcare Provider | Notified after Resident #1's fall and ordered radiographic diagnostics |
| Administrator | Interviewed regarding notification and documentation of Resident #1's fall |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted following a complaint and investigation of an accident involving a resident who fell due to failure to secure a wheelchair during van loading.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0689: The facility failed to ensure the resident environment was free from accident hazards by not securing a wheelchair during van loading, resulting in a resident fall causing scapular and rib fractures.
Report Facts
Residents Affected: 1
Date of Incident: Nov 3, 2025
Date of Survey: Dec 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Failed to lock wheelchair wheels causing resident fall; terminated. |
| LPN #1 | Licensed Practical Nurse | Received report of fall and instructed CNA to return resident for assessment. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding incident and resident condition post-fall. |
| LPN #4 | Licensed Practical Nurse | Assessed resident after fall and notified Nurse Practitioner. |
| NP #1 | Nurse Practitioner | Ordered diagnostic testing and hospital transport for resident. |
| Administrator | Facility Administrator | Confirmed CNA #3 failed to follow policy resulting in resident fall. |
| Maintenance Supervisor | Maintenance Supervisor | Explained proper procedure for wheelchair lift platform safety. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with care plan implementation and provision of structured activities for residents, focusing on participation in activities and individualized care plans.
Findings
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.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions. Two residents were not provided structured activities as outlined in their care plans.
F 0679: The facility failed to provide activities to meet all residents' needs. Two residents were not engaged in activities designed to meet their physical and mental needs and interests.
Report Facts
Residents affected: 2
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Confirmed care details for Resident #1 and explained activity appropriateness. | |
| Activities Director | Acknowledged oversight in not including Resident #1 in music activity. | |
| Director of Nursing (DON) | Confirmed lack of resident engagement in activities and staff follow-through. | |
| Administrator | Stated expectation for daily structured activities for all residents. | |
| Licensed Practical Nurse (LPN) #1 | Responsible for care planning and explained importance of following care plans. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 6, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to implement comprehensive care plans, inadequate supervision leading to resident elopement, and improper incontinent care at Pine Forest Health and Rehabilitation.
Complaint Details
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.
Findings
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.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan for two residents, Resident #41 and Resident #98, with measurable objectives and timetables.
F 0689: The facility failed to provide adequate supervision and preadmission risk assessment to prevent Resident #211 from eloping unsupervised, resulting in immediate jeopardy to resident health or safety.
F 0690: The facility failed to provide appropriate incontinent care for Resident #98, resulting in the resident being heavily soiled with urine and at risk for infection.
Report Facts
Residents reviewed: 24
Residents affected: 2
Residents affected: 1
Distance eloped: 600
BIMS score: 13
BIMS score: 6
Admission date: Jan 22, 2024
Admission date: Apr 7, 2025
Admission date: Jun 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in findings related to failure to follow care plan and improper incontinent care for Resident #98 |
| CNA #4 | Certified Nursing Assistant | Named in findings related to failure to follow care plan and improper incontinent care for Resident #98 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding care plan adherence and elopement incident |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding elopement incident |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan failures, elopement incident, and incontinent care |
| Administrator | Administrator | Interviewed regarding elopement incident and corrective actions |
| Receptionist | Receptionist | Interviewed regarding door release leading to elopement |
| Family Nurse Practitioner | Family Nurse Practitioner | Interviewed regarding medical orders following elopement |
| Social Services Director #1 | Social Services Director | Interviewed regarding wandering book updates and resident monitoring |
| Resident Representative | Resident Representative | Interviewed regarding notification of elopement |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident and concerns about care plan implementation, infection control, and quality assurance.
Complaint Details
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.
Findings
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.
Deficiencies (6)
F600: The facility failed to protect Resident #211 from elopement, resulting in immediate jeopardy when the resident exited unsupervised and was found in a busy intersection.
F0656: The facility failed to implement a comprehensive care plan for Residents #41 and #98, resulting in inadequate hygiene and repositioning care.
F0686: The facility failed to provide wound care for Resident #98 in a manner that promotes healing and prevents infection, including failure to perform peri-care before wound care.
F0689: The facility failed to provide adequate supervision and preadmission risk assessment to prevent Resident #211 from exiting the facility unsupervised, resulting in immediate jeopardy.
F0865: The facility's Quality Assurance and Performance Improvement Committee failed to sustain improvements related to care plan adherence and infection control from prior surveys.
F0880: The facility failed to prevent infection spread during PEG tube care for Resident #14 and suprapubic catheter care for Resident #62 by not following proper infection control procedures.
Report Facts
Residents sampled: 24
Distance resident eloped: 600
Temperature: 86
Deficiencies cited: 6
BIMS score: 13
BIMS score: 6
BIMS score: 99
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Interviewed about elopement event and staff response |
| Licensed Practical Nurse #3 | LPN | Interviewed about elopement event and staff response |
| Director of Nursing | DON | Interviewed about elopement event, care plan audits, and infection control |
| Assistant Director of Nursing | ADON | Interviewed about elopement event and corrective actions |
| Administrator | Administrator | Interviewed about elopement event, corrective actions, and prior deficiencies |
| Certified Nursing Assistant #1 | CNA | Interviewed about elopement event and resident retrieval |
| Family Nurse Practitioner | FNP | Ordered hospital transfer for Resident #211 after elopement |
| Registered Nurse #1 | RN | Completed Wandering Risk Screen and Elopement Evaluation for Resident #211 |
| Social Services Director #1 | SSD | Responsible for updating wandering binder and resident assessments |
| Certified Nursing Assistant #2 | CNA | Interviewed about care plan noncompliance for Resident #98 and Resident #41 |
| Licensed Practical Nurse #4 | LPN | Observed failing to wear gown during PEG tube medication administration |
| Licensed Practical Nurse #5 | LPN | Observed improper catheter care technique for Resident #62 |
| Registered Nurse #2 | RN/Infection Preventionist | Interviewed about infection control breaches |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 26, 2025
Visit Reason
The inspection was conducted following a complaint alleging physical abuse by a Certified Nurse Aide (CNA) against Resident #1 during care, involving use of physical force to prevent the resident from hitting the CNA.
Complaint Details
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.
Findings
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.
Deficiencies (2)
F 0600: The facility failed to protect Resident #1 from physical abuse when CNA #1 used physical force on the resident's left arm and face to prevent him from hitting her during care.
F 0656: The facility failed to develop and implement a comprehensive care plan that included interventions to manage Resident #1's behavior during care, resulting in CNA #1 not following the care plan to stop and return if the resident became agitated.
Report Facts
Residents sampled: 5
Residents affected: 1
BIMS score: 7
Date of incident: Jan 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Admitted to using physical force on Resident #1 and was sent home pending investigation | |
| Licensed Practical Nurse (LPN) #1 | Reported the allegation, interviewed resident and staff, and evaluated resident | |
| Director of Nursing (DON) | Conducted phone interview with resident, confirmed care plan expectations, and concluded abuse was not substantiated | |
| Certified Nurse Aide (CNA) #2 | Assisted during incident and provided statements | |
| Certified Nurse Aide (CNA) #3 and CNA #4 | Reported resident injuries and provided statements | |
| Registered Nurse (RN) #1, MDS Coordinator | Explained comprehensive care plan and its role | |
| Licensed Practical Nurse (LPN) #3, MDS and Care Planning | Stated staff are expected to follow comprehensive care plan | |
| Administrator | Reviewed investigation and agreed abuse was not substantiated |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to investigate complaints and grievances related to resident care, call light accessibility, grievance resolution, and safety during resident transfers at Pine Forest Health and Rehabilitation.
Complaint Details
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.
Findings
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.
Deficiencies (3)
F 0558: The facility failed to ensure call lights were within reach for two of seven residents, Resident #3 and Resident #6, potentially limiting their ability to call for assistance.
F 0585: The facility failed to acknowledge grievances, make prompt efforts to resolve them, and communicate progress to residents and families for two of seven sampled residents, Resident #2 and Resident #3.
F 0689: The facility failed to secure a resident in a mechanical lift and maintain necessary supervision during a transfer, resulting in a laceration requiring staples and an Emergency Department visit for Resident #1.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
BIMS score: 6
BIMS score: 7
BIMS score: 15
BIMS score: 11
Incident date: Dec 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Social Worker | Received and managed grievances from Resident #3's family |
| Certified Nurse Aide #1 | CNA | Reported call lights were to be within reach of residents |
| Certified Nurse Aide #2 | CNA | Confirmed call lights were to be within reach of residents |
| Licensed Practical Nurse #2 | LPN | Reported staff made rounds to ensure timely care and call light accessibility |
| Director of Nursing | DON | Expected call lights to be within reach and participated in investigation of Resident #1 fall |
| Administrator | Administrator | Expected call lights to be within reach and supported grievance process improvements |
| Certified Nurse Aide #3 | CNA | Involved in Resident #1 fall incident during mechanical lift transfer |
| Licensed Practical Nurse #1 | LPN | Prepared Incident Report for Resident #1 fall |
| Licensed Practical Nurse #2 | LPN, Staff Educator | Provided training on mechanical lift use and safety |
| Social Worker #2 | Social Worker | Participated in Resident Council meeting and grievance process |
| Resident Council President | Resident Council President | Reported unresolved grievances in council meetings |
| Activity Director | Activity Director | Arranged resident council meetings and presented grievances to Interdisciplinary Team |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 18, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging failure to implement individualized care plans related to Activities of Daily Living (ADL) care, specifically personal hygiene and grooming, for several residents.
Complaint Details
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.
Findings
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.
Deficiencies (3)
F656: The facility failed to implement individualized care plans for ADL care related to personal hygiene for Residents #1, #5, #6, and #7, resulting in inadequate grooming including dirty fingernails and toenails.
F677: The facility failed to ensure dependent residents received necessary services to maintain adequate grooming, including nail care and removal of unwanted facial hair, for Residents #1, #5, #6, and #7.
F0865: The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program, evidenced by re-cited deficiencies related to ADL care and grooming from a prior annual survey.
Report Facts
Residents sampled: 7
Residents affected: 4
Physician nail care order date: 2023
BIMS scores: 15
BIMS scores: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Reported nurses provide fingernail trimming and CNAs clean fingernails; instructed to report long nails | |
| Licensed Practical Nurse (LPN) #1 | Confirmed fingernail trimming by nurses and importance of following care plans | |
| Certified Nursing Assistant (CNA) #2 | Assigned to Resident #7; unaware of care plan communication and had not removed unwanted facial hair | |
| Staff Development Nurse (SDN) | Confirmed in-service training on grooming and ADL care for direct care staff | |
| Director of Nurses (DON) | Expected ADL care including nail and facial hair grooming according to care plans | |
| Administrator | Confirmed expectations for daily ADL grooming care and attendance at QAPI meetings |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 5, 2023
Visit Reason
The inspection was an annual and complaint survey conducted to assess compliance with regulatory requirements related to resident care, including pressure ulcer prevention and treatment, care planning, and staff competency.
Findings
The facility failed to protect residents from neglect related to pressure ulcer care, failed to develop and revise comprehensive care plans, failed to provide adequate wound assessments and treatments, and failed to ensure staff competency in wound care. Immediate Jeopardy was identified but removed after corrective actions including staff training, policy review, and audits.
Deficiencies (7)
F600: The facility failed to protect residents from neglect by not providing timely pressure ulcer assessments, care, and treatment, resulting in harm to residents and immediate jeopardy.
F656: The facility failed to develop and implement comprehensive care plans with measurable interventions for residents with pressure ulcers and other care needs, resulting in harm and immediate jeopardy.
F657: The facility failed to revise resident-centered care plans to reflect current physician orders and prevent worsening of pressure ulcers, resulting in harm and immediate jeopardy.
F677: The facility failed to provide appropriate care for a resident with limited range of motion by not applying a prescribed right elbow extensor splint, risking decline.
F677: The facility failed to provide adequate grooming and nail care for dependent residents, resulting in long, jagged nails and uncombed hair.
F686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents with pressure ulcers, resulting in harm and immediate jeopardy.
F726: The facility failed to ensure nurses and nurse aides had appropriate competencies for pressure ulcer staging, assessment, and treatment, resulting in harm and immediate jeopardy.
Report Facts
Residents reviewed for care plans: 22
Residents reviewed for pressure ulcers: 4
Residents with pressure ulcer deficiencies: 2
Residents with ADL care deficiencies: 2
Residents with ROM care deficiency: 1
Pressure ulcer measurements: 7
Pressure ulcer measurements: 6.5
Braden Scale score: 13
Braden Scale score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Wound Care Nurse | Named in wound care assessment and documentation deficiencies for Resident #53 and #89 |
| RN #3 | Admission Nurse | Named in wound care assessment and documentation deficiencies; not comfortable staging wounds |
| RN #4 | Previous Wound Care Nurse | Left facility before deficiencies noted; responsible for wound care documentation |
| DON | Director of Nursing | Named in oversight failures related to wound care and care plan revisions |
| CNA #14 | Certified Nurse Aide | Observed not changing Resident #53 timely and leaving wound exposed |
| LPN #4 | Care Plan Nurse | Named in care plan development deficiencies |
| RN #2 | MDS Coordinator/Care Plan Nurse | Named in care plan development deficiencies |
| Administrator | Named in oversight and corrective action implementation | |
| PTA | Physical Therapy Assistant | Named in failure to apply splint for Resident #87 |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 5, 2023
Visit Reason
The inspection was an annual and complaint survey conducted to assess compliance with regulatory requirements including resident rights, abuse and neglect prevention, comprehensive care planning, pressure ulcer care, infection control, and COVID-19 vaccination.
Findings
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.
Deficiencies (9)
F0561: The facility failed to honor resident self-determination by not facilitating a resident's request to get up and participate in activities.
F0600: The facility failed to protect residents from neglect by not providing timely pressure ulcer assessments, wound care, turning and repositioning, and ensuring residents were clean and dry.
F0656: The facility failed to develop and implement comprehensive care plans with measurable interventions for residents with pressure ulcers and other care needs.
F0657: The facility failed to revise resident-centered comprehensive care plan interventions for residents with pressure ulcers to prevent worsening or complications.
F0677: The facility failed to provide appropriate care for a resident with limited range of motion by not applying a prescribed right elbow extensor splint.
F0726: The facility failed to ensure nurses and nurse aides had appropriate competencies to assess, stage, and treat pressure ulcers.
F0806: The facility failed to provide food that accommodates resident allergies, intolerances, and preferences, and failed to provide alternative menu options.
F0880: The facility failed to provide proper incontinent care, ensure catheter bags were not lying on the floor, and ensure staff wore proper PPE when entering a COVID-19 positive resident's room.
F0887: The facility failed to ensure dependent residents received the COVID-19 vaccine in a timely manner.
Report Facts
Residents reviewed for pressure ulcers: 4
Residents reviewed for food preferences: 22
Residents reviewed for COVID-19 vaccination: 22
Residents affected by neglect: 5
Residents affected by failure to honor self-determination: 1
Residents affected by inadequate grooming: 2
Residents affected by failure to provide ROM care: 1
Residents affected by infection control issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Wound Care Nurse | Named in wound care assessment and documentation deficiencies |
| RN #3 | Admission Nurse | Named in wound care assessment and documentation deficiencies |
| RN Unit Manager #1 | Registered Nurse Unit Manager | Named in resident self-determination and grooming findings |
| CNA #14 | Certified Nursing Assistant | Named in neglect and wound care observation |
| DON | Director of Nursing | Named in multiple interviews regarding wound care and facility oversight |
| LPN #4 | Care Plan Nurse | Named in care plan development and revision deficiencies |
| CNA #6 | Certified Nursing Assistant | Named in infection control observation |
| CNA #10 | Certified Nursing Assistant | Named in infection control observation |
| CNA #11 | Certified Nursing Assistant | Named in infection control observation |
| LPN #2 | Charge Nurse | Named in splint care deficiency |
| PTA | Physical Therapy Assistant | Named in splint care deficiency |
| Administrator | Facility Administrator | Named in multiple interviews regarding oversight and corrective actions |
| RN #2 | MDS Coordinator/Care Plan Nurse | Named in care plan development and revision deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Mar 26, 2021
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, safety, and facility compliance with regulations.
Complaint Details
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.
Findings
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.
Deficiencies (9)
F 0561: The facility failed to honor resident food preferences for Resident #46 by serving disliked foods such as grits and macaroni and cheese despite documented dislikes and resident complaints.
F 0585: The facility failed to maintain safekeeping of Resident #29's belongings, specifically a missing black leather coat, and did not properly document or follow up on the grievance.
F 0608: The facility failed to report an allegation of marijuana use in a timely manner to local police and the Attorney General's Office for Resident #25.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities regarding Resident #25's marijuana use allegation.
F 0677: The facility failed to provide adequate activities of daily living care for Residents #46 and #55, including failure to provide scheduled showers and proper nail care.
F 0689: The facility failed to supervise residents adequately, as evidenced by Resident #25 testing positive for cannabis while in the facility.
F 0759: The facility failed to ensure medication error rates were below 5%, with two residents (#42 and #63) not rinsing their mouths after inhaler use as required.
F 0880: The facility failed to prevent possible spread of infection when CNA #7 did not perform hand hygiene before and after providing incontinence care to Resident #44.
F 0921: The facility failed to maintain equipment safely, as Resident #40's closet door was off its tracks and leaning inside the closet, and the room door did not close properly.
Report Facts
Medication error rate: 8.8
Marijuana purchase amounts: 140
BIMS score: 15
BIMS score: 14
BIMS score: 15
BIMS score: 4
BIMS score: 11
BIMS score: 0
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Man #3 | Maintenance Staff | Named in marijuana sale allegation and investigation related to Resident #25. |
| Dietary Employee #1 | Dietary Manager | Interviewed regarding resident food preferences and meal service issues. |
| Registered Nurse #1 | Director of Nursing (DON) | Interviewed regarding food preferences, ADL care, and medication administration. |
| Certified Nursing Assistant #1 | CNA | Observed serving disliked food to Resident #46. |
| Certified Nursing Assistant #5 | CNA | Interviewed about nail care for Resident #55. |
| Certified Nursing Assistant #6 | CNA | Interviewed about nail care for Resident #55. |
| Certified Nursing Assistant #7 | CNA | Observed and interviewed regarding hand hygiene during incontinence care for Resident #44. |
| Registered Nurse #4 | Assistant Director of Nursing | Acknowledged bathing schedule issues for Resident #46. |
| Licensed Practical Nurse #1 | LPN | Observed medication administration error for Resident #42. |
| Licensed Practical Nurse #2 | LPN | Observed medication administration error for Resident #63. |
| Social Worker #2 | Social Worker | Interviewed regarding Resident #25's visits and supervision. |
| Medical Director | MD | Interviewed regarding Resident #25's marijuana and opioid use. |
| Maintenance Staff #1 | Maintenance Staff | Interviewed regarding broken closet and room doors in Resident #40's room. |
Viewing
Loading inspection reports...
