Inspection Reports for
River Chase Village

The facility failed to properly document records of testing the fire sprinkler system in accordance with NFPA 101 and NFPA 25 standards, affecting the entire facility with 54 residents. No other deficiencies were cited.

The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.

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

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and there were no deficiencies cited.

Complaint Investigations MS #2596555 and MS #2597784 were conducted for quality of care, misappropriation, neglect, and resident discharge/transfer rights. The facility was found in compliance and no deficiencies were cited.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint Investigations MS #2596555 and MS #2597784 were conducted for quality of care, misappropriation, neglect, and resident discharge/transfer rights. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

The State Agency is recommending that the facility be placed back in compliance effective 03/06/25. No deficiencies were cited in this desk review.

The facility was found to be in compliance with the Life Safety Code based on the desk review and corrective measures provided.

The facility failed to revise a comprehensive care plan to include interventions related to a continuous glucose monitoring (CGM) device for a resident with diabetes. The facility also failed to follow professional standards for blood glucose monitoring, including lack of standardized documentation, physician orders, staff training, and protocols for CGM use. Additionally, the facility failed to label and date food properly in the kitchen and failed to accurately report direct care staffing hours to CMS.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in care plan revision, professional standards for services, food safety, and payroll-based journal staffing data reporting.

The facility was found in compliance with all emergency preparedness requirements. There were no Life Safety Code deficiencies cited during this survey.

K0353 - The facility failed to properly document records of testing the fire sprinkler system in accordance with NFPA standards, which had the potential to affect the entire facility. Documentation for correction of previous yellow findings from last year's annual sprinkler inspection was not produced.

The facility failed to properly document records of testing the fire sprinkler system as required by NFPA standards, potentially affecting all 54 residents at the time of the survey.

Complaint Investigations MS #26298, MS #26669, and MS #26923 were conducted related to verbal abuse and resident rights, staffing, and call bell not answered, falls, and neglect. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint investigations MS #26298, MS #26669, and MS #26923 were conducted related to verbal abuse and resident rights, staffing, and call bell not answered, falls, and neglect. The facility was found in compliance with no deficiencies cited.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

CI MS #24851 was investigated related to quality of care in regard to neglect for a resident not receiving care per physician orders. The SA determined the facility was in compliance and no deficiencies were cited.

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

Complaint MS #24851 was investigated related to neglect for a resident not receiving care per physician orders. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.

Complaint number CI MS#23632 was investigated related to infection control. The complaint was not substantiated and no deficiencies were cited.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.

Complaint number CI MS#23632 was investigated related to infection control. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with infection control regulations and there were no deficiencies cited.

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

The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 07/20/23.

The facility was found deficient in multiple areas including failure to ensure residents without advance directives received assistance, incomplete care plans for dialysis communication and nutrition, failure to provide hydration during meals for a resident at choking risk, inadequate dialysis communication and physician notification, unsecured medications left in a resident's room, and ineffective pest control with multiple flies observed throughout the facility.

The facility was found not in compliance with state licensure requirements due to failure to provide proper hydration to a resident at risk of choking and failure to maintain an effective pest control program as evidenced by multiple flies observed throughout the facility.

The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies cited in advance directives, comprehensive care plans, nutrition and hydration, dialysis communication, medication storage, and pest control.

The facility failed to maintain the emergency generator properly, as a trouble signal was observed on the generator panel during testing, although the generator was still functional and capable of transferring power within 10 seconds.

The facility failed to maintain the emergency generator in accordance with NFPA 110, as a trouble signal was observed on the generator panel during testing, although the generator was still capable of transferring power within 10 seconds.

The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.

The facility failed to report complete information about COVID-19 to the CDC's NHSN during a required seven-day period, potentially causing more than minimal harm to all residents.

Complaint Investigations MS #20360 and MS #30607 were investigated and the facility was found in compliance with no deficiencies cited.

The State Agency found the facility to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements.

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

Complaint Investigations MS #20360 and MS #20607 were conducted concurrently with the COVID-19 focused infection control survey. Deficiencies were cited and substantiated related to infection control failures.

The facility was cited for two Immediate Jeopardy deficiencies related to allowing a Certified Nursing Aide (CNA) who tested positive for COVID-19 and had not met return to work criteria to provide direct care to residents without COVID-19 infection. Three residents subsequently tested positive. The facility implemented corrective actions and the Immediate Jeopardy was removed prior to exit.

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

The complaint investigation revealed that CNA #1 tested positive for COVID-19 on 01/02/23 but was allowed to work on 01/02/23 and 01/03/23 providing direct care to COVID-19 negative residents. The facility was in a COVID-19 outbreak starting 12/29/22. The facility failed to restrict the positive staff member from working, which placed residents and staff at risk. The Immediate Jeopardy was removed on 01/26/23 after corrective actions including staff in-service, audits, and updated infection control policies.

The facility allowed a Certified Nursing Assistant (CNA #1) who tested positive for COVID-19 and was asymptomatic to provide direct care to residents without suspected or confirmed COVID-19 infection, violating infection control protocols and placing residents and staff at risk. The situation was deemed an Immediate Jeopardy (IJ) which was removed after corrective actions were implemented.

Complaint Investigations MS #20360 and MS #20607 involved allegations of failure to implement infection control measures to prevent COVID-19 transmission. The complaint was substantiated with deficiencies cited, including an Immediate Jeopardy related to allowing a COVID-19 positive CNA to provide direct care.

The facility allowed a Certified Nursing Aide (CNA) who tested positive for COVID-19 and had not met return to work criteria to provide direct patient care to residents without suspected or confirmed COVID-19 infection. This failure placed residents and staff at risk of serious harm and was determined to be an Immediate Jeopardy (IJ) that began on 1/2/23. The facility submitted an acceptable Removal Plan and the IJ was removed on 1/26/23.

The facility was found out of compliance for allowing a Certified Nursing Assistant (CNA) who tested positive for COVID-19 and was asymptomatic to provide direct care to residents without COVID-19 infection. This failure placed residents and staff at risk of serious harm. The facility implemented corrective actions and the Immediate Jeopardy was removed on 01/26/2023.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with infection control regulations and no deficiencies were cited.

The facility was found not in compliance with deficiencies cited related to comprehensive care plans, bowel/bladder incontinence and catheter care, food storage, infection prevention and control, and sprinkler system maintenance. The facility failed to follow care plans for catheter/incontinent care, failed to prevent infection and trauma, failed to label and date opened meats, and failed to maintain the fire sprinkler system properly.

The visit was complaint-related due to allegations of failure to follow care plans for catheter and incontinent care, improper infection control practices, and food safety violations. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to follow care plans for catheter and incontinent care for multiple residents, resulting in potential harm such as trauma and infection. Observations revealed improper catheter securing, repeated wiping with the same cloth area, and failure to use clean gloves properly. Additionally, the facility failed to label and date opened meats in the freezer and improperly handled soiled linen bags, risking infection spread.

Complaint investigation MS #16148 substantiated for verbal abuse involving Resident #1. Deficiencies cited for failure to prevent abuse and failure to timely report the abuse incident.

The facility was found to have failed to prevent verbal and mental abuse of Resident #1 by a Certified Nursing Assistant, failed to report the abuse incident to the Mississippi State Department of Health and local law enforcement within the required timeframe, and failed to report alleged violations promptly as required by regulation.

The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in advance directives, PASARR screening, respiratory care, staffing, garbage disposal, infection control, fire alarm system, fire drills, and electrical system maintenance.

The facility was found not in compliance with Minimum Standards for the Age and Infirm, citing deficiencies in staffing, special needs care, and garbage disposal.