Inspection Reports for Reginald P. White Nursing Facility
1451 North Lakeland Drive, Meridian, MS 39307, MS, 39307
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Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 65
Capacity: 70
Deficiencies: 0
Dec 11, 2025
Visit Reason
The State Agency conducted complaint investigations related to a fall with injury and resident health privacy at the facility from 2025-12-10 through 2025-12-11.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the complaint investigations.
Complaint Details
Complaint investigations MS #2673389 (fall with injury) and MS #2613813 (resident health privacy) were conducted and found to be unsubstantiated with no deficiencies cited.
Report Facts
Complaint investigation MS number: 2673389
Complaint investigation MS number: 2613813
Licensed bed capacity: 70
Resident census: 65
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 11, 2025
Visit Reason
The State Agency conducted complaint investigations related to a fall with injury and resident health privacy at the facility from 2025-12-10 through 2025-12-11.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint investigations MS #2673389 and MS #2613813 were conducted related to a fall with injury and resident health privacy. The complaints were not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 70
Deficiencies: 2
Oct 22, 2025
Visit Reason
The State Agency conducted a complaint investigation triggered by a facility reported incident regarding a resident fall during a mechanical lift transfer.
Findings
The facility failed to ensure a resident's right to be free from neglect when two staff members transferred a resident using a mechanical lift without the required four-person assist, resulting in the resident falling backward. The facility was found to be in past non-compliance but had implemented corrective actions prior to the survey.
Complaint Details
The complaint investigation was related to a resident fall on 8/30/25 during a mechanical lift transfer by two CNAs instead of the required four-person assist. The incident was substantiated as neglect due to failure to follow the care plan and physician orders. Both CNAs were placed on administrative leave and later terminated. The facility implemented corrective actions including staff training and quality assurance meetings.
Severity Breakdown
SS = D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident’s right to be free from neglect when two staff members completed a resident transfer with a mechanical lift without using the required four staff members, resulting in a resident fall. | SS = D |
| Failure to develop and implement a comprehensive care plan intervention related to transferring a resident with a mechanical lift as required by the resident’s care plan. | SS = D |
Report Facts
Licensed beds: 70
Resident census: 66
Date of incident: 83025
Care plan required assist: 4
Staff involved in transfer: 2
Corrective action date: 90525
State Agency survey date: 102225
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Involved in resident transfer resulting in fall; aware of four-person assist requirement but only two staff assisted |
| CNA #2 | Certified Nurse Assistant | Involved in resident transfer resulting in fall; aware of four-person assist requirement but only two staff assisted |
| Director of Nursing | Director of Nursing | Confirmed staff failed to provide necessary care and supervision during transfer; acknowledged corrective actions |
| Administrator | Facility Administrator | Confirmed facility policies and training; acknowledged failure to follow care plan and risk to resident |
| Registered Nurse/MDS #1 | Registered Nurse | Interviewed regarding care plan adherence and expectations for safe resident transfers |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 22, 2025
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 10/20/25 through 10/22/25 regarding a resident fall during a mechanical lift transfer.
Findings
The facility failed to ensure a resident's right to be free from neglect when two staff members transferred a resident with a mechanical lift without the required four staff members, resulting in the resident falling backward. The facility implemented corrective actions prior to the survey and was found in compliance at the time of inspection.
Complaint Details
The complaint investigation was triggered by a facility reported incident involving a resident fall on 8/30/25 during a mechanical lift transfer. The resident required a four-person assist but was transferred by only two CNAs, violating the care plan. Both CNAs were placed on administrative leave and later terminated. The facility conducted training and quality assurance meetings and reported the incident to the State Agency and Attorney General within the required timeframe.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a resident's right to be free from neglect when two staff members completed a resident transfer with a mechanical lift without using the required four staff members, resulting in a resident fall. |
Report Facts
Date of incident: Aug 30, 2025
Number of staff required for transfer: 4
Number of staff involved in transfer: 2
Date corrective actions implemented: Sep 5, 2025
Date survey completed: Oct 22, 2025
BIMS score: 9
Time of incident: 1027
Reporting timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Involved in resident transfer resulting in fall; placed on administrative leave and terminated |
| CNA #2 | Certified Nurse Assistant | Involved in resident transfer resulting in fall; placed on administrative leave and terminated |
| Director of Nursing | Director of Nursing | Confirmed staff failed to provide necessary care and supervision during transfer |
| Administrator | Facility Administrator | Confirmed facility policies, training, and disciplinary actions related to incident |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 5, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-05-29 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2025-07-11.
Inspection Report
Annual Inspection
Census: 64
Capacity: 70
Deficiencies: 3
May 29, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 5/27/25 through 5/29/25 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with professional standards for nursing services, quality assurance and performance improvement (QAPI) activities, and infection prevention and control practices. Deficiencies included failure to verify PEG tube placement before medication administration, failure to sustain corrective actions for infection control, and failure to follow proper infection prevention protocols during medication administration and wound care.
Severity Breakdown
SS=D: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to verify Percutaneous Endoscopic Gastrostomy (PEG) tube placement prior to administering medications for one resident. | SS=D |
| Failure of the Quality Assurance and Performance Improvement (QAPI) Committee to sustain corrective actions to prevent recurrence of infection control deficiencies. | SS=E |
| Failure to ensure staff followed appropriate infection prevention and control practices, including hand hygiene and use of personal protective equipment (PPE) during medication administration via PEG tube and wound care. | SS=E |
Report Facts
Census: 64
Total Capacity: 70
Deficiencies cited: 3
BIMS score: 11
BIMS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in deficiency for failing to verify PEG tube placement and improper infection control practices during medication administration |
| LPN #1 | Licensed Practical Nurse | Named in deficiency for failing to follow infection control protocols during wound care |
| Director of Nursing | Director of Nursing | Conducted in-services and confirmed deficiencies related to PEG tube verification and infection control |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Provided training and confirmed infection control protocol expectations |
| Nurse Educator | Nurse Educator | Conducted in-services on infection control practices |
| Nursing Home Administrator | Nursing Home Administrator | Acknowledged prior citations and QAPI focus on infection control |
Inspection Report
Annual Inspection
Deficiencies: 2
May 29, 2025
Visit Reason
The State Agency conducted an Annual Recertification Survey at the facility from 5/27/25 through 5/29/25 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with infection control standards, specifically failing to ensure staff followed appropriate infection prevention and control practices for two residents requiring Enhanced Barrier Precautions (EBP). Deficiencies involved failure of staff to perform proper hand hygiene, don appropriate personal protective equipment (PPE), and follow glove-changing protocols during medication administration and wound care.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure Registered Nurse (RN) #2 performed hand hygiene and donned appropriate PPE while administering medications via PEG tube for Resident #13 requiring Enhanced Barrier Precautions. | Level II |
| Failure to ensure Licensed Practical Nurse (LPN) #1 followed Enhanced Barrier Precautions and glove-changing protocols during wound care for Resident #45. | Level II |
Report Facts
Number of residents sampled: 18
BIMS score: 11
BIMS score: 3
Date range of survey: Survey conducted from 2025-05-27 through 2025-05-29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in infection control deficiency related to hand hygiene and PPE during medication administration |
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency related to glove changing and PPE during wound care |
| RN #3 | Infection Preventionist | Provided interview confirming infection control expectations and training |
| Acting Director of Nursing | Acting Director of Nursing | Confirmed infection control protocol breaches and assessed residents post-incident |
| Director of Nursing | Director of Nursing | Conducted in-service trainings and quality assurance monitoring related to infection control deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
May 29, 2025
Visit Reason
The visit was related to the annual survey of the facility conducted on 05/29/2025, with a desk review completed on 08/05/2025 to confirm corrective measures.
Findings
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 07/11/2025.
Inspection Report
Life Safety
Deficiencies: 0
May 28, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited during the survey.
Inspection Report
Life Safety
Deficiencies: 0
May 28, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Complaint Investigation
Census: 64
Capacity: 65
Deficiencies: 4
Feb 12, 2025
Visit Reason
The State Agency conducted complaint investigations from 2025-02-10 through 2025-02-12 related to allegations of abuse, pressure sores, quality of care, and residents' rights at Reginald P White Nursing Facility.
Findings
The facility failed to protect Resident #1 from physical abuse by a Certified Nurse Assistant who dragged the resident by his clothing down the hallway, while a Licensed Practical Nurse observed and did not intervene. The facility also failed to follow abuse reporting policies and implement care plan interventions for Resident #1's behavioral needs. Immediate Jeopardy was identified but later removed after corrective actions.
Complaint Details
Complaint Investigations CI MS #27376, #27588, and #27589 were conducted for abuse, pressure sores, quality of care, resident left soiled, physical abuse, and residents rights. Immediate Jeopardy was identified related to abuse and quality of care but was removed after corrective actions.
Severity Breakdown
Scope and Severity (S/S) of "J" (Immediate Jeopardy): 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure resident's right to be free from physical abuse by staff member dragging Resident #1 by his clothing. | Scope and Severity (S/S) of "J" (Immediate Jeopardy) |
| Failure to implement written policies to prohibit and prevent abuse, neglect, and exploitation. | Scope and Severity (S/S) of "J" (Immediate Jeopardy) |
| Failure to report alleged abuse immediately as required by policy and regulation. | Scope and Severity (S/S) of "J" (Immediate Jeopardy) |
| Failure to implement comprehensive care plan interventions for Resident #1's behavioral needs, including redirection and helmet use. | Scope and Severity (S/S) of "J" (Immediate Jeopardy) |
Report Facts
Beds licensed: 65
Residents present: 64
Staff training completion date: 2025
Immediate Jeopardy removal date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in physical abuse of Resident #1 by dragging him down hallway |
| LPN #1 | Licensed Practical Nurse | Observed abuse and failed to intervene or report in timely manner |
| RN #1 | Registered Nurse | Confirmed reporting policies and delayed reporting by LPN #1 |
| Administrator | Confirmed abuse incident and corrective actions | |
| Director of Nursing | DON | Confirmed care plan expectations and failure to intervene |
| Housekeeper | Witnessed abuse but did not report | |
| CNA #2 | Certified Nurse Assistant | Witnessed abuse but did not intervene or report |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 12, 2025
Visit Reason
The State Agency conducted complaint investigations at the facility from 2025-02-10 through 2025-02-12 related to allegations of abuse, pressure sores, quality of care, resident left soiled, physical abuse, and residents' rights.
Findings
The facility was found to have failed to protect Resident #1 from physical abuse by a Certified Nurse Assistant who dragged the resident down the hallway by his clothing on 2024-12-31. The Licensed Practical Nurse present did not intervene or report the incident timely. The facility was cited for Immediate Jeopardy and Substandard Quality of Care, which was later removed after corrective actions were implemented by 2025-01-08. The facility was in compliance at the time of the survey entrance on 2025-02-10.
Complaint Details
Complaint Investigations MS #27376, #27588, and #27589 were conducted. No deficiencies were cited related to MS #27376. MS #27588 and MS #27589 involved abuse and residents' rights. The Immediate Jeopardy and Substandard Quality of Care related to these complaints were removed after corrective actions.
Severity Breakdown
Level IV: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident's right to be free from physical abuse by a staff member, specifically Resident #1 being dragged by a CNA while an LPN observed and failed to intervene or report timely. | Level IV |
Report Facts
Dates of complaint investigation: From 2025-02-10 through 2025-02-12
Date of abuse incident: Dec 31, 2024
Date Immediate Jeopardy removed: Jan 8, 2025
Number of residents sampled: 3
BIMS score: 12
Distance resident dragged: 16
Distance resident dragged (CNA #1 statement): 20
Training period: 5
Training completion date: In-services completed on 2025-01-07
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Physically abused Resident #1 by dragging him down the hallway; terminated on 2025-01-07 |
| LPN #1 | Licensed Practical Nurse | Observed abuse and failed to intervene or report timely; terminated on 2025-01-07 |
| Administrator | Notified of Immediate Jeopardy and Substandard Quality of Care on 2025-02-11; confirmed abuse after video review | |
| DON | Director of Nurses | Notified of abuse on 2025-01-03; confirmed abuse after video review |
| RN #1 | Registered Nurse | Confirmed reporting procedures and abuse details on 2025-02-11 |
| CNA #2 | Certified Nurse Assistant | Witnessed abuse but did not intervene or report; reported event was brief |
| Campus Safety Officer | Did not witness abuse but was questioned about physical abuse on 2024-12-31 | |
| Housekeeper | Witnessed Resident #1 being pulled by clothing but did not report |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 110
Deficiencies: 0
Jun 3, 2024
Visit Reason
The State Agency conducted two complaint investigations (CI MS #24902 and CI MS #24903) at the facility on 6/3/24. The investigations focused on accidents, falls, and neglect.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Two complaint investigations were conducted: CI MS #24902 for accidents, falls, and neglect; and CI MS #24903 for accidents and falls. Both complaints were investigated with no deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 3, 2024
Visit Reason
The State Agency conducted a complaint survey at the facility for two complaints, MS #24902 and MS #24903, investigating accidents, falls, and neglect.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited.
Complaint Details
The complaint investigation involved two complaints: MS #24902 was investigated for accidents, falls, and neglect; MS #24903 was investigated for accidents and falls. Both complaints were found to be unsubstantiated as no deficiencies were cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 27, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-11 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
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 2024-02-20.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 27, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-11 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were implemented to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-02-20.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 20, 2024
Visit Reason
The State Agency conducted an onsite complaint investigation for a facility reported incident involving the transfer of a Resident with a full body mechanical lift in which the Resident fell.
Findings
No deficiencies were cited during the survey; however, the facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on the 1/11/24 survey.
Complaint Details
Complaint investigation CI MS #24110 regarding a resident fall during transfer with a mechanical lift; no deficiencies cited during this survey.
Inspection Report
Complaint Investigation
Census: 57
Capacity: 65
Deficiencies: 0
Feb 20, 2024
Visit Reason
The State Agency conducted an onsite complaint investigation for a facility reported incident involving the transfer of a resident with a full body mechanical lift in which the resident fell.
Findings
No deficiencies were cited during this survey; however, the facility remains out of compliance with Medicare and Medicaid participation requirements due to deficiencies cited on a prior survey dated 2024-01-11.
Complaint Details
Complaint investigation CI MS #24110 regarding a resident fall during transfer with a full body mechanical lift; no deficiencies cited during this investigation.
Report Facts
Census: 57
Total licensed capacity: 65
Inspection Report
Annual Inspection
Census: 59
Capacity: 65
Deficiencies: 3
Jan 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 1/8/24 through 1/11/24 to determine compliance with Medicare and Medicaid requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to resident rights, food safety, and infection prevention and control.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a resident had a dignified dining experience by not serving meals at the same time as roommate. | SS=D |
| Failure to record daily temperatures for refrigerators and freezer for six days and failure to date and label stored food in the kitchen refrigerator. | SS=F |
| Failure to prevent the spread of infection by staff not wearing face masks correctly and failure to perform hand hygiene during wound care. | SS=D |
Report Facts
Deficiencies cited: 3
Residents affected: 50
Residents census: 59
Total licensed beds: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Named in deficiency for not serving meals simultaneously and not wearing mask correctly. |
| Director of Nursing | Director of Nursing (RN) | Involved in assessment, training, and corrective actions related to deficiencies. |
| Dietary Manager | Dietary Manager | Involved in assessment and corrective actions related to food safety deficiencies. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Observed failing to perform hand hygiene during wound care. |
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 2024-01-08 through 2024-01-11 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with residents' rights, safe food handling procedures, and infection control standards. Deficiencies included failure to ensure dignified dining experience, failure to record refrigerator and freezer temperatures and label stored food, and failure to adhere to infection control practices such as proper mask wearing and hand hygiene during wound care.
Severity Breakdown
Level II: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a resident had a dignified dining experience for one of seven resident dining observations (Resident #160). | Level II |
| Failed to record daily temperatures for refrigerators and freezer for the last six days prior to survey and failed to date and label stored food in facility refrigerator. | — |
| Failed to prevent the possibility of the spread of infection as evidenced by staff failing to correctly wear a face mask and failing to perform hand hygiene during wound care (Resident #57). | Level II |
Report Facts
Residents potentially affected: 50
Resident dining observations: 7
Wounds observed: 5
Residents monitored: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Assistant #1 | Certified Nurse Aide | Named in deficiency related to failure to serve meals simultaneously and improper mask wearing. |
| Director of Nursing | RN | Involved in assessment, training, and corrective actions related to deficiencies. |
| Dietary Manager | Involved in assessment, training, and corrective actions related to food handling deficiencies. | |
| Licensed Practical Nurse #1 | LPN | Observed failing to perform hand hygiene during wound care. |
| Dietary Account Manager | Interviewed regarding food safety and temperature logs. | |
| Certified Nurses Assistant Coordinator | Set up and served resident meal tray involved in dining deficiency. | |
| Certified Nurse Aide #2 | Interviewed regarding meal tray delivery. | |
| Certified Nurse Aide #1 | Interviewed and observed regarding mask wearing and meal tray delivery. | |
| Dietary Worker #3 | Conferenced on deficient practice of not maintaining temperature logs. | |
| Nursing Supervisors | RN | Involved in training and monitoring compliance with meal service and infection control. |
| Infection Preventionist | IP | Confirmed outbreak status and importance of mask wearing. |
Inspection Report
Life Safety
Deficiencies: 0
Jan 10, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited during this survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 10, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 6, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-10-20 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
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.
Inspection Report
Annual Inspection
Census: 57
Capacity: 60
Deficiencies: 1
Oct 20, 2022
Visit Reason
The State Agency conducted an Annual Recertification Survey at the facility from 10/17/22 through 10/22/22 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance due to failure to provide mail delivery on Saturdays for three sampled residents, potentially affecting all 57 residents. The facility policy stated mail should be delivered six days a week, but interviews confirmed residents did not receive mail on Saturdays. A corrective plan was implemented to ensure mail delivery on Saturdays.
Deficiencies (1)
| Description |
|---|
| Failure to provide mail delivery on Saturdays for three (3) of 15 sampled residents, potentially affecting all 57 residents. |
Report Facts
Licensed bed capacity: 60
Resident census: 57
Sampled residents affected: 3
Residents potentially affected: 57
BIMS scores: 15
BIMS score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Social Worker | Informed residents about mail delivery changes and explained mail distribution process | |
| Administrator | Interviewed regarding mail delivery on Saturdays and facility's commitment to improve | |
| Director of Nursing | In-serviced on mail distribution process as part of corrective action | |
| Activity Director | In-serviced staff and monitored mail distribution and logging |
Inspection Report
Annual Inspection
Census: 57
Capacity: 60
Deficiencies: 3
Oct 20, 2022
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/17/22 through 10/20/22 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with requirements and cited for deficiencies related to protection/management of personal funds, right to forms of communication with privacy, and accuracy of assessments.
Severity Breakdown
SS=D: 2
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure residents had readily available and reasonable access to their personal funds seven days a week for four of 15 residents sampled. | SS=D |
| Facility failed to provide mail delivery on Saturdays for three of 15 sampled residents, potentially affecting all 57 residents. | SS=C |
| Facility failed to accurately code the Admission Minimum Data Set (MDS) related to a resident's reentry from an acute care hospital for one of 17 residents reviewed. | SS=D |
Report Facts
Deficiencies cited: 3
Residents sampled: 15
Residents reviewed for MDS accuracy: 17
Licensed beds: 60
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | MDS Nurse | Interviewed regarding MDS coding for Resident #46. |
| Licensed Practical Nurse #1 | LPN | Interviewed about Money Call process. |
| Director of Nursing | DON | Interviewed about Money Call and MDS coding. |
| Administrator | Interviewed about Money Call and mail delivery. | |
| Licensed Social Worker | Educated residents about access to funds and mail delivery; involved in corrective actions. | |
| Activity Director | Involved in mail distribution corrective actions and monitoring. |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 20, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 10/20/22 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming that corrective measures were implemented and compliance was sustained. The State Agency recommended the facility be placed back in compliance effective 11/28/22.
Inspection Report
Life Safety
Deficiencies: 0
Oct 19, 2022
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Oct 19, 2022
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 60
Deficiencies: 0
Dec 8, 2021
Visit Reason
The visit was conducted as a complaint investigation (CI MS# 18345) regarding allegations of employee to resident abuse and quality of care/treatment not being provided according to physician orders.
Findings
The facility was found to be in compliance with regulations and the complaint was not substantiated. No deficiencies were cited.
Complaint Details
Complaint CI MS# 18345 was not substantiated for employee to resident abuse and quality of care/treatment concerns.
Report Facts
Census: 51
Total licensed capacity: 60
Inspection Report
Complaint Investigation
Census: 51
Capacity: 60
Deficiencies: 0
Dec 8, 2021
Visit Reason
The State Agency conducted a complaint survey at the facility from 12/7/2021 to 12/8/2021 to investigate allegations of employee to resident abuse and services not being provided according to physician orders.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements, did not substantiate the complaint, and no deficiencies were cited.
Complaint Details
The complaint for employee to resident abuse and services not being provided according to physician orders was not substantiated.
Report Facts
Licensed beds: 60
Census: 51
Inspection Report
Complaint Investigation
Census: 51
Capacity: 60
Deficiencies: 0
Dec 8, 2021
Visit Reason
The State Agency conducted a complaint survey at the facility from 12/7/2021 to 12/8/2021 regarding allegations of employee to resident abuse and services not being provided according to physician orders.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements, the complaint was not substantiated, and no deficiencies were cited.
Complaint Details
Complaint for employee to resident abuse and services not being provided according to physician orders was not substantiated.
Report Facts
Licensed beds: 60
Census: 51
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Apr 28, 2021
Visit Reason
The State Agency conducted an onsite complaint investigation CI MS #17440 on 04/28/2021.
Findings
The complaint was unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with Medicaid participation requirements.
Complaint Details
Complaint investigation CI MS #17440 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 28, 2021
Visit Reason
The State Agency conducted the survey for Complaint Investigation (CI) #17740 on 04/28/2021.
Findings
The State Agency did not substantiate Complaint Investigation #17740 and no deficiencies were cited. The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Complaint Details
Complaint Investigation (CI) #17740 was not substantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Census: 44
Deficiencies: 0
Nov 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 11/30/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 11/30/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Deficiencies: 1
Sep 14, 2020
Visit Reason
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).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 09/07/2020 and 09/13/2020, as required by regulation. This failure to report had the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 43
Capacity: 53
Deficiencies: 0
May 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 43
Capacity: 53
Deficiencies: 0
May 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 5/22/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 43
Total Capacity: 53
Inspection Report
Annual Inspection
Deficiencies: 1
Nov 7, 2019
Visit Reason
The State Agency conducted an annual recertification and licensure survey from 11/4/2019 to 11/7/2019 to determine compliance with State Licensure Regulations for the Aged or Infirm.
Findings
The facility was found not in compliance with residents' rights regulations, specifically failing to assist three residents to vote in the Governor's election on 11/6/2019. The facility initiated corrective actions including in-servicing social workers and monitoring compliance to ensure residents' voting rights are honored.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to honor resident rights by not assisting three of six residents to vote in the Governor's election on 11/6/19. | Level II |
Report Facts
Residents not assisted to vote: 3
BIMS score: 15
Survey dates: Survey conducted from 2019-11-04 to 2019-11-07.
Inspection Report
Annual Inspection
Census: 53
Capacity: 53
Deficiencies: 2
Nov 7, 2019
Visit Reason
The State Agency conducted an annual recertification survey from 11/4/2019 to 11/7/2019 to determine compliance with Medicare/Medicaid participation requirements.
Findings
The facility was found not in substantial compliance due to deficiencies related to resident rights (failure to assist residents in voting) and infection prevention and control (failure to prevent possible spread of infection during medication administration). The facility also met Life Safety Code and Emergency Preparedness requirements with no deficiencies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to assist three residents who wanted to vote in the Governor's election on 11/6/19. | SS=D |
| Failure to prevent possible spread of infection during medication administration for two of three observations, including placing gloves and medications in pockets. | SS=D |
Report Facts
Residents present: 53
Licensed capacity: 53
Residents not assisted to vote: 3
Medication administration observations: 3
Medication administration failures: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in infection prevention deficiency for placing gloves in pocket |
| Licensed Practical Nurse #2 | LPN | Named in infection prevention deficiency for placing medications in pocket |
| Director of Nursing | DON | Conducted in-service and assessments related to infection prevention and voting assistance |
| Social Worker | Failed to assist residents in voting as required | |
| Registered Nurse #1 | Facility Educator | Provided training on infection control |
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