Inspection Reports for River Place Nursing Center
1126 Earl Frye Boulevard, Amory, MS 38821, MS, 38821
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 21, 2026
Visit Reason
The State Agency conducted a desk review on 01/21/26 of information related to the annual survey conducted on 12/17/25 to verify correction of deficient practices and compliance with the Life Safety Code.
Findings
The facility was found to have implemented corrective measures and was recommended to be placed back in compliance effective 01/16/26. The emergency preparedness survey conducted on 12/17/25 revealed no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 20, 2026
Visit Reason
The State Agency conducted a desk review of information provided related to the annual survey completed on 2025-12-18 to verify corrective measures taken by the facility.
Findings
The facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2026-01-16.
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 20, 2026
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-12-18 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 facility was recommended to be placed back in compliance effective 2026-01-16.
Inspection Report
Annual Inspection
Census: 49
Capacity: 60
Deficiencies: 5
Dec 18, 2025
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 12/15/2025 through 12/18/2025 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for multiple deficiencies including failure to ensure call lights were within reach, failure to respect resident self-determination regarding advance directives, failure to implement gradual dose reduction orders for psychotropic drugs, failure to provide services to prevent worsening of contractures, and failure to store medications securely.
Severity Breakdown
SS = D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure that a call light was within reach for one resident (Resident #30). | SS = D |
| Failure to ensure a resident's right for self-determination related to end-of-life care was respected; resident did not receive opportunity to sign own code status directive (Resident #7). | SS = D |
| Failure to initiate and implement a physician's order for gradual dose reduction of psychotropic drugs for one resident (Resident #39). | SS = D |
| Failure to provide services to maintain or prevent worsening of contractures for one resident (Resident #38). | SS = D |
| Failure to store medications in a secure manner; resident had access to medication at bedside (Resident #47). | SS = D |
Report Facts
Deficiencies cited: 5
Census: 49
Total Capacity: 60
BIMS Score: 9
BIMS Score: 15
BIMS Score: 12
BIMS Score: 10
BIMS Score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding call light placement, medication orders, and medication storage. | |
| Certified Nursing Assistant #1 | Confirmed call light was not within reach of Resident #30. | |
| Occupational Therapist | Interviewed regarding contractures of Resident #38 and therapy assessments. | |
| Administrator | Acknowledged resident rights and contracture interventions. |
Inspection Report
Annual Inspection
Census: 49
Capacity: 60
Deficiencies: 2
Dec 18, 2025
Visit Reason
The State Agency conducted an annual re-certification survey at River Place Nursing Center from 12/15/2025 through 12/18/2025 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 residents' rights and range of motion requirements. Specifically, the facility failed to ensure two residents' rights to self-determination and accommodation of needs, including proper end-of-life care consent and call light accessibility. Additionally, the facility failed to provide adequate services to maintain or prevent worsening of contractures for one resident.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident's right to self-determination and accommodation of needs for two residents, including failure to provide education and consent opportunity for end-of-life care and failure to keep call light within reach. | Level II |
| Failed to provide services to maintain or prevent worsening of contractures for one resident with contractures to left wrist and fingers. | Level II |
Report Facts
Census: 49
Total Capacity: 60
Residents Sampled: 24
Residents Reviewed for Contractures: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged failure to ensure resident's right to self-determination and end-of-life care consent | |
| Director of Nursing (DON) | Confirmed call light should be within reach and acknowledged failure to provide range of motion exercises for resident with contractures | |
| Occupational Therapist (OT) | Provided assessment and comments on resident's contractures and therapy needs | |
| Certified Nursing Assistant (CNA) #1 | Confirmed call light was not within reach of Resident #30 |
Inspection Report
Life Safety
Census: 52
Deficiencies: 1
Dec 18, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on the fire alarm system testing and maintenance.
Findings
The facility failed to maintain a properly functioning fire alarm system as the fire alarm panel was found in 'trouble mode' due to a dialer issue, although the system remained operational. This deficiency affected all 52 residents present during the survey.
Severity Breakdown
SS = F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Fire alarm panel was in 'trouble mode' for dialer issue, failing to meet NFPA 72 and NFPA 101 requirements. | SS = F |
Report Facts
Residents affected: 52
Inspection Report
Complaint Investigation
Census: 59
Capacity: 60
Deficiencies: 0
May 12, 2025
Visit Reason
The State Agency conducted a Complaint Investigation related to accidents and hazards at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint Investigation (CI MS #28900) related to accidents and hazards; no deficiencies were cited.
Report Facts
Census: 59
Total licensed capacity: 60
Inspection Report
Complaint Investigation
Census: 59
Capacity: 60
Deficiencies: 0
May 12, 2025
Visit Reason
The State Agency conducted an onsite complaint investigation related to accidents and hazards.
Findings
The facility was found to be in compliance with the Rules and Regulations for the Aged and Infirmed and no deficiencies were cited.
Complaint Details
Complaint investigation MS28900 related to accidents and hazards; no deficiencies were cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 10, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-05-30 to verify corrective measures taken by the facility.
Findings
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 2024-07-07.
Report Facts
Annual survey date: May 30, 2024
Desk review completion date: Jul 10, 2024
Compliance effective date: Jul 7, 2024
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 10, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-05-30 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation, and the agency recommended the facility be placed back in compliance effective 2024-07-07.
Report Facts
Annual survey completion date: May 30, 2024
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 1
May 30, 2024
Visit Reason
The annual recertification survey was conducted from 05/28/2024 through 05/30/2024 to assess compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm.
Findings
The facility was found not in compliance with residents' rights policies, specifically failing to document and follow up on a resident's repeated grievances regarding shower schedules. Resident #39 reported not receiving showers as scheduled, and the grievance process was not properly followed or resolved.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to document a summary of the resident's repeated grievances regarding showers and any corrective actions and follow-up for Resident #39. | Level II |
Report Facts
Census: 55
Total Capacity: 60
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Grievance Officer | Named in relation to failure to document and follow up on Resident #39's grievances |
| RN #1 | Registered Nurse | Developed sign-off sheet for showers and confirmed Resident #39 did not always receive scheduled showers |
| RN #2 | Registered Nurse | Acknowledged widespread knowledge of Resident #39's shower complaints |
| Director of Nurses | Director of Nurses | Unaware of Resident #39's complaints and confirmed grievance process was not properly followed |
| Administrator | Administrator | Aware of bathing concerns and confirmed lack of resolution or follow-up on grievance |
| CNA #1 | Certified Nurse Aide | Confirmed Resident #39's complaints about not receiving showers |
| CNA #2 | Certified Nurse Aide | Confirmed Resident #39's complaints about not receiving showers |
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 1
May 30, 2024
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 05/28/24 through 05/30/24 to assess compliance with Medicare and Medicaid requirements.
Findings
The facility was found not in compliance due to failure to document and resolve a resident's repeated grievances regarding shower schedules and follow-up actions. Specifically, Resident #39's complaints about not receiving showers as scheduled were not properly documented or addressed through the grievance process.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document a summary of Resident #39's repeated grievances regarding showers and any corrective actions and follow-up. | SS=D |
Report Facts
Census: 55
Total Capacity: 60
Grievance Completion Date: Jul 7, 2024
MDS BIMS Score: 15
Inspection Report
Deficiencies: 0
May 29, 2024
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 and no deficiencies were cited during the survey.
Inspection Report
Life Safety
Deficiencies: 0
May 29, 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, and no LSC deficiencies were cited during this survey.
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 2
Apr 20, 2023
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 4/17/23 to 4/20/23 to determine compliance with state licensure requirements for institutions for the aged or infirm.
Findings
The facility was found not in compliance with state licensure requirements with deficiencies cited at M190 related to restraint use and M500 related to residents' rights, including failure to ensure a resident was free from restraint and failure to protect a resident's right to privacy in her room.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Use of a body alarm that restricted the movements of a resident who could turn and position themselves without a physician's order or proper restraint assessment for Resident #43. | Level II |
| Failure to protect Resident #39's right to privacy when another resident wandered into her room without consent. | Level II |
Report Facts
Residents reviewed: 54
Bed capacity: 60
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to removal of restraint alarm and staff in-service |
| CNA #4 | Certified Nursing Assistant | Provided care to Resident #43 and interviewed about restraint use |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding use of chair alarm on Resident #43 |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Confirmed restraint use and resident capabilities for Resident #43 |
| Social Services Director | Social Services Director | Interviewed regarding Resident #39's privacy complaint and corrective actions |
| Administrator | Administrator | Involved in addressing Resident #39's privacy concerns and staff in-service |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed wandering behaviors of Resident #36 |
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 6
Apr 20, 2023
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 4/17/23 through 4/20/23 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found non-compliant with multiple requirements including Resident Rights, Personal Privacy, Grievances, Right to Be Free From Physical Restraints, Comprehensive Assessments, Care Plan Development, and Quality of Care. Specific deficiencies included failure to deliver mail on Saturdays, failure to protect resident privacy, failure to document and resolve grievances, improper use of restraints, incomplete care plans, and failure to implement pressure ulcer prevention measures.
Severity Breakdown
SS=F: 1
SS=D: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to promptly deliver postal mail to residents on Saturdays for all 54 residents. | SS=F |
| Failure to protect a resident's right to privacy in her room due to wandering resident intrusion. | SS=D |
| Failure to record, initiate, and resolve a grievance for a resident regarding wandering intrusion. | SS=D |
| Use of a body alarm as a physical restraint without physician order or consent for one resident. | SS=D |
| Failure to develop and implement comprehensive care plans for residents with wandering behavior, use of body alarm, and positioning needs. | SS=D |
| Failure to apply heel booties and float heels while in bed for one resident, risking pressure ulcers. | SS=D |
Report Facts
Deficiency citations: 7
Census: 54
Total capacity: 60
BIMS score: 15
BIMS score: 9
BIMS score: 10
BIMS score: 14
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 20, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 04/20/23 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 06/09/23.
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 20, 2023
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 04/20/23 to verify the facility's compliance with Medicare and Medicaid requirements.
Findings
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 06/09/23.
Inspection Report
Life Safety
Deficiencies: 0
Apr 18, 2023
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
Apr 18, 2023
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: 58
Capacity: 60
Deficiencies: 0
Sep 20, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility on 9/20/22 to investigate allegations related to Resident Neglect, Quality of Care concerning weight loss, and Accidents related to falls.
Findings
The survey determined that the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaint was not substantiated and no deficiencies were cited.
Complaint Details
Complaint survey CI MS #18628 was not substantiated for Resident Neglect, Quality of Care related to weight loss, or Accidents related to falls.
Report Facts
Census: 58
Total Capacity: 60
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Sep 20, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility on 9/20/22 to investigate allegations related to Resident Neglect, Quality of Care concerning weight loss, and Accidents related to falls.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint was not substantiated and no deficiencies were cited.
Complaint Details
Complaint survey CI MS #18628 was conducted. The complaint for Resident Neglect, Quality of Care related to weight loss, and Accidents related to falls was not substantiated.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Jun 29, 2021
Visit Reason
The State Agency conducted a complaint survey on 6/28/21 through 6/29/21 for complaint investigation MS# 17858.
Findings
The complaint was not substantiated and 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.
Complaint Details
Complaint investigation MS# 17858 was not substantiated.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Jun 29, 2021
Visit Reason
The State Agency conducted a complaint survey on 6/28/21 through 6/29/21 to investigate a complaint regarding nursing services and quality of care related to a nurse's failure to administer a dose of medicine.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and did not substantiate the complaint related to the medication administration error.
Complaint Details
Complaint CI MS #17858 regarding nursing services and quality of care related to a nurse failure to administer a dose of medicine that may have led to a resident having seizures and requiring hospitalization was not substantiated.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Feb 25, 2021
Visit Reason
The inspection was an annual recertification survey conducted from 2/23/21 through 2/25/21, including complaint investigations CI MS #17345 and CI MS #17388.
Findings
The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The survey substantiated abuse and in-service training deficiencies related to complaint CI MS #17345, while complaint CI MS #17388 was not substantiated. The facility failed to prevent abuse and neglect involving a Certified Nursing Assistant (CNA) and failed to provide required in-service training on abuse and neglect.
Complaint Details
Complaint investigation CI MS #17345 was substantiated for abuse and in-service training deficiencies. Complaint CI MS #17388 was not substantiated and cited no deficiencies.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to prevent verbal and physical abuse by a Certified Nursing Assistant (CNA) involving Resident #53. | Level II |
| Failure to provide appropriate in-service training on abuse and neglect to staff, specifically CNA #1 had no documented in-service since 2015. | Level II |
Report Facts
Residents reviewed for abuse and neglect: 11
BIMS score: 15
BIMS score: 14
BIMS score: 9
In-service frequency: 4
Date of incident: Dec 1, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in abuse incident involving Resident #53 and failure to comply with investigation leading to termination. |
| Resident #47 | Resident and former CNA | Reported abuse incident and provided detailed account of CNA #1's behavior. |
| Physical Therapist #1 | Physical Therapist | Received report of abuse from Resident #47 and confirmed follow-up actions. |
| Administrator | Facility Administrator | Managed investigation, terminated CNA #1, and provided information on staff in-service compliance. |
| Staff Development Nurse | Staff Development Nurse | Responsible for in-service training and maintaining employee roster for compliance. |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Feb 25, 2021
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations from 2/23/21 through 2/25/21 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance due to substantiated abuse involving a Certified Nursing Assistant and failure to provide required in-service training for nurse aides. The complaint investigation for one allegation was substantiated with citations, while another was not substantiated.
Complaint Details
The complaint investigation CI MS #17345 was substantiated for abuse, citing deficiencies F600 and F947 related to lack of in-service education. The complaint investigation CI MS #17388 was not substantiated with no citations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to prevent verbal and physical abuse by a Certified Nursing Assistant involving a resident during care. | SS=D |
| Failure to provide required in-service training for nurse aides regarding abuse and neglect. | SS=D |
Report Facts
Residents reviewed for abuse and neglect: 11
BIMS score: 15
BIMS score: 14
BIMS score: 9
In-service training hours required: 12
In-service audit frequency: 10
In-service audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal and physical abuse incident and failure to comply with investigation; terminated 12-1-2020. |
| Resident #47 | Resident | Reported abuse incident and was interviewed multiple times. |
| Physical Therapist #1 | Physical Therapist | Reported resident's account of abuse and confirmed follow-up. |
| Administrator | Facility Administrator | Managed investigation, terminated CNA #1, and provided interview details. |
| Director of Nursing | Director of Nursing | Reviewed abuse investigation procedures and oversaw corrective actions. |
| Staff Development Nurse | Staff Development Nurse | Confirmed in-service training records and implementation of employee roster system. |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Feb 25, 2021
Visit Reason
The inspection was conducted as an annual recertification survey along with complaint investigations CI MS #17345 and CI MS #17388 from 2021-02-23 through 2021-02-25.
Findings
The State Agency substantiated complaint investigation CI MS #17345 for abuse and in-service training deficiencies, but did not substantiate CI MS #17388 and cited no deficiencies for it.
Complaint Details
Complaint investigation CI MS #17345 was substantiated for abuse and in-service training deficiencies; CI MS #17388 was not substantiated and had no deficiencies cited.
Deficiencies (2)
| Description |
|---|
| Abuse substantiated at tag M500 |
| In-service training deficiency at tag M515 |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Feb 25, 2021
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations from 2/23/21 through 2/25/21 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. The complaint investigation CI MS #17345 was substantiated for abuse and cited deficiencies related to lack of in-service education, while CI MS #17388 was not substantiated with no related citations.
Complaint Details
Complaint investigation CI MS #17345 was substantiated for abuse; CI MS #17388 was not substantiated.
Deficiencies (2)
| Description |
|---|
| Abuse substantiated related to complaint CI MS #17345 |
| Lack of in-service education cited (F600 and F947) |
Report Facts
Census: 59
Inspection Report
Life Safety
Deficiencies: 0
Feb 24, 2021
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
Deficiencies: 0
Feb 24, 2021
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. No deficiencies were cited.
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 0
Dec 28, 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 for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/28/2020 to assess compliance with relevant regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness for COVID-19.
Inspection Report
Routine
Census: 43
Capacity: 60
Deficiencies: 0
May 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 5/28/20 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
Census: 43
Capacity: 60
Deficiencies: 0
May 28, 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 for COVID-19 preparation.
Inspection Report
Annual Inspection
Census: 58
Capacity: 60
Deficiencies: 2
Mar 27, 2019
Visit Reason
The State Agency conducted an Annual Recertification survey at the facility from 3/25/19 to 3/28/19 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to resident self-administration of medications and food procurement, storage, preparation, and service under sanitary conditions. No Life Safety Code deficiencies or emergency preparedness issues were identified.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident was assessed for self-administration of medications as clinically appropriate, specifically Resident #6 had medications left on the bedside without assessment or proper policy adherence. | SS=D |
| Failure to ensure foods were stored, prepared, and served under sanitary conditions, including unlabeled and undated food items in the freezer, food particles on equipment, grease accumulation, dust on vents, ice buildup, and multiple reheatings of food served to residents. | SS=E |
Report Facts
Licensed beds: 60
Resident census: 58
Medications in cup: 11
Food reheating count: 3
Food temperature: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Assessed Resident #6 for medication self-administration and involved in plan of correction |
| Dietary Manager | Dietary Manager | Observed food storage and sanitation issues, conducted staff in-service, and implemented corrective actions |
| Interim Administrator | Interim Administrator and Director of Clinical Operations | Acknowledged awareness of medication and food safety deficiencies |
Inspection Report
Annual Inspection
Census: 58
Capacity: 60
Deficiencies: 1
Mar 27, 2019
Visit Reason
The inspection was an annual recertification survey conducted to assess compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Findings
The facility was found non-compliant due to unsafe food handling procedures, including failure to store, prepare, and serve food under sanitary conditions and reheating foods multiple times before serving residents.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure foods were stored, prepared, and served under sanitary conditions during kitchen observations. | Level II |
Report Facts
Beds licensed: 60
Residents present: 58
Reheating instances: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed reheating practices and sanitation issues; involved in corrective actions | |
| Interim Administrator | Acknowledged reheating and sanitation deficiencies | |
| Director of Clinical Operations | Acknowledged reheating and sanitation deficiencies |
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