Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 6, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory standards, including care planning, blood glucose monitoring, food safety, and staffing reporting.
Findings
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.
Deficiencies (4)
Failed to revise a comprehensive care plan for Diabetes Mellitus to include interventions related to a continuous glucose monitoring (CGM) device for one resident.
Failed to follow professional standards for blood glucose monitoring by not ensuring standardized documentation, physician orders, staff training on CGM use and maintenance, and clear protocols on when to use CGM versus traditional glucometer.
Failed to label and date food stored in the refrigerator and freezer and failed to dispose of spoiled foods during kitchen observations.
Failed to accurately report to CMS the direct care hours based on payroll and other verifiable and auditable data for the fourth quarter of fiscal year 2024.
Report Facts
Care plans reviewed: 20
Residents affected: 1
Days of kitchen observations: 4
Staffing quarters reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Unaware of CGM device use and care plan revision for Resident #49 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed Resident #49 requesting insulin and reported no formal training on CGM device |
| Registered Nurse #1 | Registered Nurse | Assisted Resident #49 in changing CGM device, no formal training on device |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Used CGM device for blood glucose readings, no formal training |
| Nurse Practitioner | Nurse Practitioner | Unaware of Resident #49 CGM device use and advised policies needed before implementation |
| Director of Nursing | Director of Nursing | Unaware of CGM device use, expected staff to report changes and follow standards |
| Administrator | Administrator | Expected staff to follow standard practices, confirmed lack of CGM policies, and staffing reporting issues |
| Dietary Manager | Dietary Manager | Confirmed food labeling and storage deficiencies |
| Registered Dietitian | Registered Dietitian | Confirmed staff training and food safety standards |
| Admissions Coordinator | Admissions Coordinator | Responsible for CNA scheduling, reported issues with agency CNA time tracking affecting staffing data |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility River Chase Village to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 6
Date: Jun 22, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, dialysis care, medication storage, nutrition, and pest control at River Chase Village nursing home.
Findings
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.
Deficiencies (6)
Failed to ensure residents without advance directives received information or assistance in formulating an advance directive for 4 of 24 residents reviewed.
Failed to implement a care plan regarding physician notification, dialysis communication, and failed to provide thicken liquids for 2 of 24 care plans reviewed.
Failed to provide hydration during a meal to a resident who was a choking risk.
Failed to maintain communication with the physician and maintain dialysis communication sheets for a resident who receives dialysis services for 7 of 34 days.
Failed to store medications in a locked medication cart; medications were left unsecured on a resident's bedside table.
Failed to ensure an effective pest control program as evidenced by multiple flies observed throughout the facility for three of four days of survey.
Report Facts
Residents reviewed for advance directives: 24
Residents without advance directives: 4
Care plans reviewed: 24
Care plans deficient: 2
Dialysis communication sheets missing: 7
Dialysis days with missing communication: 7
Medication carts reviewed: 3
Flies observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Left medications unsecured in Resident #6's room |
| DON | Director of Nursing | Confirmed missing dialysis communication sheets and unsecured medications |
| Admissions Director | Admitted not discussing advance directives with residents or representatives | |
| Medical Records Nurse | Provided dialysis communication notes to surveyor | |
| LPN #1 | Licensed Practical Nurse | Confirmed missing dialysis communication sheets and lack of documentation |
| Dietary Manager | Confirmed missing hydration on meal trays and confusion about Ensure Plus orders | |
| CNA #3 | Certified Nursing Assistant | Confirmed resident not served Ensure Plus with meals |
| CNA #4 | Certified Nursing Assistant | Confirmed resident did not receive hydration on meal tray |
| Dialysis Nurse | Confirmed missing dialysis communication forms and resident dialysis attendance |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Feb 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent staff who tested positive for COVID-19 from working with residents who did not have COVID-19 infection.
Complaint Details
The complaint investigation found 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 did not notify residents or staff about the positive staff member working. Three residents subsequently tested positive for COVID-19. The facility implemented corrective actions including in-services starting 01/25/23, audits confirming no other positive staff working, and added agenda items to QA meetings.
Findings
The facility allowed a Certified Nursing Assistant (CNA #1) who tested positive for COVID-19 and was asymptomatic to provide direct patient care to residents without suspected or confirmed COVID-19 infection on 01/02/23 and 01/03/23. This failure to implement infection control measures placed residents and staff at risk of serious harm. The facility was in a COVID-19 outbreak and did not notify residents or staff about the positive staff member working. The situation was determined to be Immediate Jeopardy but was removed on 01/26/23 after corrective actions including staff in-services and audits.
Deficiencies (2)
Facility administration failed to ensure residents were protected by allowing staff who tested positive for COVID-19 to work with residents who did not have COVID-19 infection.
Failure to implement infection control measures to prevent transmission of COVID-19 among residents and staff.
Report Facts
Residents assigned to CNA #1 on 01/02/23: 11
Residents assigned to CNA #1 on 01/03/23: 13
Facility census on 01/02/23: 53
Facility census on 01/03/23: 55
Licensed/certified staff on 01/02/23: 10
Licensed/certified staff on 01/03/23: 8
Residents testing positive for COVID-19: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Allowed to work while COVID-19 positive and asymptomatic, providing direct care to residents |
| Director of Nursing | Director of Nursing (DON) | Authorized CNA #1 to work while COVID-19 positive; conducted staff in-services |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy; approved removal plan |
| Administrator in Training | Administrator in Training (AIT) | Aware of staffing contingency plan and COVID-19 positive staff working |
| Infection Preventionist | Infection Preventionist Nurse | Monitored infection control and COVID-19 testing |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Feb 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent staff who tested positive for COVID-19 from working with residents who were COVID-19 negative.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility administration failed to ensure residents were able to attain or maintain the highest practicable physical, mental, and psychosocial well-being by allowing staff who tested positive for COVID-19 to work with residents who did not have COVID-19 infection.
Failure to implement infection control measures to prevent transmission of COVID-19 among residents and staff.
Report Facts
Residents assigned to CNA #1 on 01/02/23: 11
Facility census on 01/02/23: 53
Facility census on 01/03/23: 55
Licensed/certified staff on 01/02/23: 10
Licensed/certified staff on 01/03/23: 8
Residents tested positive for COVID-19 after exposure: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Allowed to work while COVID-19 positive and asymptomatic, providing direct care to residents |
| Director of Nursing | Director of Nursing (DON) | Authorized CNA #1 to work while positive due to staffing shortages and outbreak; conducted staff in-services |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy; approved removal plan; aware of outbreak and staffing contingency |
| Administrator in Training | Administrator in Training (AIT) | Supported DON's decision to allow positive staff to work during staffing shortages |
| Infection Preventionist | Infection Preventionist (IP) Nurse | Monitored infection control; aware of positive staff working and potential risk |
| Medical Director | Medical Director | Unaware staff were working while COVID-19 positive; expected adherence to CDC guidelines |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 12, 2020
Visit Reason
The inspection was conducted due to complaints regarding failure to follow care plans related to catheter and incontinent care, infection prevention, and food safety practices at River Chase Village nursing home.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to follow care plan related to catheter/incontinent care for Residents #28, #14, and #35, including failure to secure catheters and improper cleaning techniques.
Failed to provide appropriate care to prevent infection and trauma during catheter/incontinent care for Residents #28, #14, and #35.
Failed to label and date opened meats in the meat freezer for one of two days of observation.
Failed to prevent possible spread of infection during catheter/incontinent care observations for Residents #28 and #35, including placing soiled linen bags on the floor and using soiled gloves improperly.
Report Facts
Residents affected: 3
Opened chicken breasts: 10
Cube steak patties: 12
Wipes used improperly: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Failed to secure catheter tubing and used improper wiping technique for Resident #35 |
| CNA #1 | Certified Nursing Assistant | Used same gloves for multiple tasks and improper wiping technique during incontinent care for Resident #28 |
| CNA #4 | Certified Nursing Assistant | Failed to secure catheter tubing and caused tension during catheter care for Resident #14 |
| Director of Nursing | Director of Nursing | Provided interviews confirming care plan requirements and training for catheter and incontinent care |
| RN #1 | Registered Nurse | Confirmed expectations for catheter care and care plan adherence |
| Dietary Manager | Dietary Manager | Confirmed failure to label and date opened food items in the meat freezer |
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