Inspection Reports for Poplar Springs Nursing Center

A health survey was conducted at Poplar Springs Nursing Center, LLC on July 24, 2025, to determine compliance with State Licensure Regulations.

The survey identified one or more violations of the State Licensure Regulations, detailed in an attached Licensure Violation Report.

The State Agency conducted an annual recertification survey at the facility from 7/21/25 to 7/24/25 to assess compliance with Minimum Standards of Operations for Alzheimer's Disease/Dementia Care unit and Institutions for the Aged or Infirm.

The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care unit and Institutions for the Aged or Infirm, with no deficiencies cited.

The State Agency conducted a desk review related to the annual survey completed on 07/24/25 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficiencies from the annual survey, and the State Agency recommended the facility be placed back in compliance effective 08/21/25.

The survey was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on smoke barrier construction and emergency preparedness.

The facility met all emergency preparedness requirements with no deficiencies cited. However, a deficiency was found in the smoke barrier construction where unsealed holes around data cables and electrical piping compromised the half-hour fire resistance rating in two of six smoke compartments.

The inspection was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on smoke barrier construction and fire safety standards.

The facility failed to provide the required half-hour fire resistance rating in the smoke barrier wall, affecting two of six smoke compartments. Unsealed holes around data cables and electrical piping near the A/B Nurses Station compromised the smoke barrier's ability to resist smoke passage.

The inspection was conducted as the facility's annual survey to assess compliance with applicable provisions of the 2012 Edition of the Life Safety Code and emergency preparedness requirements.

The facility was found to have corrected previous deficiencies related to the Life Safety Code and was recommended to be placed back in compliance effective 08/04/25. The emergency preparedness survey revealed no deficiencies.

The State Agency conducted a desk review related to a complaint survey completed on 2025-04-10 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was found to be in compliance with the Minimum Standards of Operation, and the State Agency recommended placing the facility back in compliance effective 2025-04-30.

The complaint survey was completed on 2025-04-10. The desk review on 2025-05-05 confirmed compliance and recommended the facility be placed back in compliance effective 2025-04-30.

The State Agency conducted a desk review related to a complaint survey completed on 2025-04-10 to assess the facility's corrective actions and compliance with Medicare and Medicaid requirements.

The facility provided information confirming corrective measures were implemented to address the deficient practice, and the State Agency recommended the facility be placed back in compliance effective 2025-04-30.

The visit was complaint-related, reviewing corrective actions following a complaint survey on 2025-04-10. The facility was found to have corrected deficiencies and was recommended to be placed back in compliance.

The State Agency conducted two complaint investigations at the facility from April 9, 2025 through April 10, 2025, related to physical environment and resident rights, abuse, and neglect.

The facility was found non-compliant with resident rights due to an incident where a Certified Nursing Assistant (CNA) used inappropriate tone and language, delayed assistance to a resident, and was subsequently terminated. The resident was assessed and found to have no psychological harm. The facility provided in-services on abuse, neglect, and resident rights to staff and implemented monitoring to ensure compliance.

Two complaint investigations were conducted: CI MS #28191 for physical environment with no deficiencies found, and CI MS #28280 for resident rights, abuse, and neglect where a Level II deficiency was cited related to verbal abuse and neglect by a CNA towards Resident #1.

The State Agency conducted two complaint investigations at the facility from 4/9/25 through 4/10/25, investigating physical environment and abuse, neglect, and resident rights.

The facility was found non-compliant with Medicare and Medicaid participation requirements. No deficiencies were found related to the physical environment complaint. Deficiencies were cited for failure to ensure resident rights and failure to thoroughly investigate an abuse allegation involving a Certified Nursing Assistant (CNA #1) who used inappropriate language and delayed assistance to Resident #1, resulting in verbal abuse and neglect.

Two complaint investigations were conducted: MS #28191 for physical environment with no deficiencies found, and MS #28280 for abuse, neglect, and resident rights where deficiencies F550 and F610 were cited. Resident #1 alleged verbal abuse and neglect by CNA #1 on 3/14/2025. The facility terminated CNA #1 and provided in-services on abuse and neglect. The investigation failed to include interviews of other residents who may have been affected.

The State Agency conducted a desk review on 10/01/24 of information related to the annual survey completed on 08/29/24 to verify corrective measures taken by the facility.

The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 09/25/24.

The State Agency conducted a desk review of information related to the annual survey completed on 2024-08-29 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was found to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2024-09-25.

The State Agency conducted an annual recertification survey at the facility from 08/26/24 through 08/29/24 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple regulatory requirements including safe and homelike environment, comprehensive care planning, bowel/bladder care, respiratory care, medication administration, and infection prevention and control.

The State Agency conducted an annual recertification survey at the facility from 08/26/2024 through 08/29/2024 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with several standards including urinary incontinence care, respiratory care, floor safety, and infection control. Deficiencies included inadequate perineal care leading to risk of infection, failure to date oxygen tubing, broken floor tiles posing safety hazards, and improper hand hygiene practices by staff.

The survey was conducted to assess the facility's compliance with emergency preparedness requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies noted.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), specifically regarding corridor wall construction and fire resistance.

The facility failed to protect corridors as required by NFPA 101 Section 19.3.6.1.1, with corridor walls and doors incapable of resisting the passage of smoke. This deficiency affected 11 of the 86 residents present during the survey.

The State Agency conducted a desk review related to a complaint survey completed on 2024-07-16 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-08-21.

The visit was related to a complaint survey completed on 2024-07-16. The facility's corrective measures were reviewed and found satisfactory, leading to a recommendation of compliance restoration.

The State Agency conducted a Complaint Investigation (CI), MS #25651, related to pharmaceutical services, resident neglect, and misappropriation of property at the facility.

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

Complaint Investigation MS #25651 was related to pharmaceutical services, resident neglect, and misappropriation of property. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a complaint investigation (CI #25651) related to pharmaceutical services, neglect, and misappropriation of property at the facility.

The facility failed to provide all physician-prescribed medications to a resident who went out on therapeutic leave, resulting in noncompliance with Medicare and Medicaid participation requirements.

Complaint Investigation MS #25651 was substantiated related to pharmaceutical services, neglect, and misappropriation of property.

The State Agency conducted a complaint investigation at the facility on 6/4/24 related to allegations of drug diversion of a controlled narcotic medication.

The facility failed to protect a resident from misappropriation of a controlled medication by a Licensed Practical Nurse (LPN #1) who tested positive for opioids and morphine without a prescription and was terminated. The facility conducted an immediate investigation, narcotic audits, staff training, and reported the incident to appropriate authorities.

The complaint investigation (CI MS #24629) was substantiated as the facility confirmed drug diversion by LPN #1 who signed out narcotics multiple times without a prescription and tested positive for opioids and morphine. The resident tested negative for opioids. The facility took corrective actions prior to the survey date.

The State Agency conducted a complaint investigation at the facility on 6/4/24 related to allegations of drug diversion of a controlled narcotic medication.

The facility failed to protect a resident from misappropriation of a controlled medication by a licensed practical nurse who diverted Norco medication intended for Resident #1. The nurse tested positive for opioids without a prescription and was terminated. The facility conducted an immediate investigation, reported the incident to relevant authorities, and implemented corrective actions to achieve compliance by 3/26/24.

The complaint investigation (MS #24629) was substantiated. The facility was found non-compliant due to drug diversion by LPN #1 who signed out medication multiple times without a prescription and tested positive for opioids and morphine. The resident tested negative for opioids. The facility reported the incident to the State Agency, Attorney General Office, State Board of Nursing, and Board of Pharmacy.

The State Agency conducted a complaint investigation related to abuse at the facility.

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

Complaint Investigation (CI MS #24041) related to abuse was conducted and found to be unsubstantiated with no deficiencies cited.

The State Agency conducted a complaint investigation related to abuse at the facility on 3/25/24.

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

Complaint Investigation (CI MS #24041) related to abuse was conducted and found to be unsubstantiated with no deficiencies cited.

The State Agency conducted a Complaint Investigation related to allegations of abuse and neglect of several residents at the facility from 11/14/2023 through 11/15/2023.

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

Investigation was related to allegations of abuse and neglect of several residents. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation related to allegations of abuse and neglect for several residents from 11/14/23 through 11/15/23.

The facility was found to be in compliance with the Standards for participation in Medicare and Medicaid, and no deficiencies were cited.

Investigation MS #23292 was related to allegations of abuse and neglect for several residents and was found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation related to Quality of Care issues including responsible party not notified of hospital transfer, resident not groomed adequately, and call lights not assessable for residents.

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

Complaint Investigation (CI MS #22953) related to Quality of Care with issues of responsible party not notified of hospital transfer, resident not groomed adequately, and call lights not assessable for residents. No deficiencies were cited.

The State Agency conducted a Complaint Investigation related to Quality of Care issues including responsible party not notified of hospital transfer, resident not groomed adequately, and call lights not assessable for residents.

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

Complaint Investigation (CI MS #22953) related to Quality of Care with issues of notification of hospital transfer, resident grooming, and call light accessibility. The complaint was not substantiated as no deficiencies were cited.

The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

The facility failed to report complete COVID-19 information to the NHSN during a required seven-day reporting period between 08/21/2023 and 08/27/2023, which has the potential to cause more than minimal harm to residents.

The State Agency conducted a Complaint Investigation at the facility on 7/20/23 to investigate pressure sores.

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

Complaint Investigation MS #21667 regarding pressure sores was investigated and found to have no deficiencies.

The State Agency conducted a complaint investigation at the facility on 7/20/23 related to pressure sores.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited regarding the investigated pressure sores.

Complaint Investigation (CI), MS #21667 regarding pressure sores was investigated with no deficiencies cited.

The State Agency conducted a desk review of information related to the annual survey completed on 2023-03-16 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2023-04-19.

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

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

The State Agency conducted a desk review related to the annual survey completed on 03/16/23 to verify corrective measures and compliance with Medicare and Medicaid requirements.

The facility provided information confirming that corrective measures were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 04/19/23.

The State Agency conducted an annual re-certification survey at the facility from 03/13/23 through 03/16/23 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with residents' rights and special needs care requirements. Specifically, the facility failed to provide privacy covers for urinary catheter drainage bags for one resident and failed to provide storage bags for oxygen cannulas and nebulizer masks for three residents receiving respiratory treatment.

The State Agency conducted an annual re-certification survey at the facility from 03-13-23 through 03-16-23 to determine compliance with Medicare and Medicaid requirements.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident rights, respiratory care, and infection prevention and control. Specific issues included failure to provide privacy covers for catheter drainage bags, improper storage of respiratory equipment, and staff not properly wearing face masks or performing hand hygiene.

The State Agency conducted an annual recertification survey at the facility from 03/13/23 through 03/16/23 to assess compliance with the Minimum Standards of Operations for Alzheimer Disease/Dementia Care Unit.

The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer Disease/Dementia Care Unit and no deficiencies were cited.

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

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.

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

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

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), specifically regarding smoke barrier doors in the facility.

The facility failed to provide 20-minute fire resistance rating smoke barrier doors as required by NFPA 101, affecting two of five smoke compartments and 28 of 80 residents. The A & B Hall smoke barrier doors did not close to a positive latching position and were incapable of resisting smoke passage.

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

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.

The State Agency conducted a desk review related to the annual survey conducted on 03/14/23 to confirm corrective measures and compliance with the Life Safety Code.

The facility had implemented measures to correct deficient practices and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 03/29/23.

The State Agency conducted an annual recertification survey at the facility from 03/13/23 through 03/16/23 to assess compliance with the Minimum Standards of Operations for Alzheimer Disease/Dementia Care Unit.

The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer Disease/Dementia Care Unit and no deficiencies were cited during the survey.

The State Agency conducted a desk review related to a complaint survey completed on 2022-11-02 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2022-11-28.

The visit was complaint-related, and the facility was found to be in compliance based on the desk review of information related to the complaint survey.

The State Agency conducted a desk review related to a complaint survey completed on 2022-11-02 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2022-11-28.

The visit was related to a complaint survey completed on 2022-11-02. The facility's corrective measures were reviewed and found satisfactory.

The State Agency conducted a Complaint Investigation (CI) MS #18529 at the facility from 2022-11-01 through 2022-11-02 due to allegations of abuse.

The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. The investigation substantiated abuse against one resident, Resident #1, involving physical abuse by Licensed Practical Nurse #1. Both the LPN and a Certified Nursing Assistant who witnessed but did not report the incident were terminated. The facility implemented multiple in-services and corrective actions to prevent recurrence.

The complaint investigation MS #18529 was substantiated for abuse. The physical abuse incident occurred on 2022-02-13 involving Licensed Practical Nurse #1 and Resident #1. The facility reported the incident to local police, Medicaid Fraud Control Unit, Resident's Representative, and Department of Health. Both involved employees were terminated.

The State Agency conducted a Complaint Investigation (CI), MS #18529 at the facility from 11/01/22 through 11/02/22 due to allegations of abuse.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to substantiated abuse involving one resident. Licensed Practical Nurse #1 physically abused Resident #1, and Certified Nursing Assistant #1 failed to report the incident. Both employees were terminated.

The complaint investigation MS #18529 was substantiated for abuse involving Resident #1. The investigation confirmed physical abuse by Licensed Practical Nurse #1 on 2/13/22, witnessed by Certified Nursing Assistant #1 who failed to report it. Both employees were terminated. The resident had moderate cognitive impairment and no physical injuries from the incident.

The inspection was conducted as a result of three complaint investigations (CI #17155, CI #17480, and CI #17548) during the period from 07/13/2021 to 07/19/2021.

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

Three complaint investigations were conducted, resulting in an unsubstantiated outcome with no deficiencies cited.

The State Survey Agency conducted three complaint investigations at the facility from 07/13/2021 to 07/19/2021 regarding neglect, quality of care, dental services, and pressure wounds.

The investigations found the facility in compliance with Medicare and Medicaid requirements, with no substantiated neglect or deficiencies. Documentation showed consistent resident and wound care, despite residents' overall health decline.

Three complaint investigations (CI #17155, CI #17480, and CI #17548) were conducted regarding neglect, quality of care, dental services, and pressure ulcers. None were substantiated due to lack of evidence.

The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).

The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period between 11/30/2020 and 12/06/2020, which has the potential to cause more than minimal harm to residents.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 9/29/20 to assess compliance with infection control regulations and implementation of CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with infection control regulations and had implemented the CMS and CDC recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 9/29/20 to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

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

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

A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey along with a complaint investigation, CI MS #17014, was conducted by the State Agency due to a complaint concerning the lack of PPE in the facility.

The facility was found to be in compliance with infection control regulations and had implemented recommended COVID-19 practices. The complaint regarding lack of PPE was not substantiated as adequate PPE was observed throughout the facility. No deficiencies were cited.

The complaint investigation CI MS #17014 concerning lack of PPE was unsubstantiated; no deficiencies were cited.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.

A Covid-19 Focused Infection Control Survey along with a complaint investigation, CI MS #17014, was conducted by the State Agency due to a complaint concerning the lack of PPE in the facility.

The facility was found to be in compliance with infection control regulations and had implemented recommended practices for COVID-19. The complaint regarding lack of PPE was not substantiated as adequate PPE was observed throughout the facility. No deficiencies were cited.

Complaint CI MS #17014 concerning lack of PPE was investigated and found unsubstantiated; no deficiencies were cited.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

The State Agency conducted a Complaint Investigation (CI MS #16605) at the facility from 03/09/2020 through 03/11/2020 due to allegations of abuse and neglect.

The facility was found not in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm, substantiating abuse and neglect involving three residents. Multiple employees were found to have verbally and physically abused residents, including slapping, verbal threats, and withholding food. The facility took immediate action by placing the employees on administrative leave, notifying authorities, and conducting in-services on abuse and neglect.

The complaint investigation substantiated abuse and neglect involving Residents #1, #2, and #3. Allegations included physical abuse such as slapping and verbal abuse including threats and intimidation by two Certified Nursing Assistants (CNAs). The facility reported the incidents to the Mississippi State Department of Health, Sheriff’s Department, Medicaid Fraud Criminal Unit, and Attorney General’s Office. Investigations were conducted, and employees involved were terminated.

The State Agency conducted a complaint investigation (CI MS #16605) from 03/09/2020 through 03/11/2020 due to allegations of abuse and neglect involving three residents.

The facility was found not in compliance with Medicare and Medicaid participation requirements, substantiating abuse and neglect allegations involving three residents. The investigation revealed verbal, physical abuse and neglect by two CNAs towards Residents #1, #2, and #3, with failure to report the incidents timely to appropriate agencies.

The complaint investigation substantiated abuse and neglect involving Residents #1, #2, and #3. The facility failed to prevent abuse by two CNAs and failed to report the abuse within the required timeframe. The allegations included physical abuse (slapping, hitting), verbal abuse (threats, harsh language), and neglect (removal of food tray, call light). The facility self-reported the incidents and terminated the employees involved.

The State Agency conducted an annual recertification survey to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with several requirements including resident rights, notice requirements before transfer/discharge, accuracy of assessments, development and implementation of comprehensive care plans, and activities meeting resident interests and needs. Specific issues included failure to ensure resident privacy, failure to provide written transfer notifications, inaccurate mental illness status on assessments, missing care plans for certain residents, and inadequate activity programming.

The State Agency conducted a licensure survey from 12/2/19 to 12/5/19 to determine compliance with the Minimum Standards for The Institutions For The Aged And Infirm.

The facility was found not in compliance with resident rights and activity program requirements. Resident #59's right to privacy was violated when toileting, and the facility failed to provide activities meeting the preferences and needs of Residents #6 and #47 over multiple days.

The complaint investigation was conducted from 4/24/19 to 4/25/19 to determine if there was abuse or neglect related to accidents.

The surveyor was unable to substantiate abuse or neglect related to accidents during the complaint investigation.

The complaint investigation was conducted but abuse/neglect related to accidents was not substantiated.

The State Agency conducted an annual survey at the facility from 11/27/18 to 11/30/18 to determine compliance with Medicare and Medicaid Requirements for Participation.

The facility was found not in compliance due to failure to limit the use of PRN psychotropic medications to 14 days for two residents. No life safety code deficiencies or emergency preparedness deficiencies were cited.