Inspection Reports for
Ruleville Community Care Center
800 Stansel Drive, Ruleville, MS, 38771
Back to Facility Profile54 Reports
Inspection Report — Jul 1, 2026
Complaint Investigation
Date: Jul 1, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #3049220 and CI MS #3064977) at the facility on 7/1/26.
Complaint Details
Complaint Investigations CI MS #3049220 and CI MS #3064977 were conducted and no deficiencies were cited; the facility was found in compliance.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services and no deficiencies were cited.
Report Facts
Complaint Investigations conducted: 2
Inspection Report — Jun 2, 2026
Complaint Investigation
Date: Jun 2, 2026
Visit Reason
The State Agency conducted Complaint Investigations (CI) MS #2791731, CI MS #2804475, CI MS #2966708, CI MS #2978585, CI MS #3028991 and CI MS #3029743 at the facility on 6/2/26.
Complaint Details
Complaint Investigations CI MS #2791731, CI MS #2804475, CI MS #2966708, CI MS #2978585, CI MS #3028991 and CI MS #3029743 were conducted and no deficiencies were cited; the facility was found in compliance.
Findings
During the survey, the SA determined that the facility was in compliance with the requirements of the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and there were no deficiencies cited.
Report Facts
Complaint Investigations conducted: 6
Inspection Report — Feb 26, 2026
Complaint Investigation
Date: Feb 26, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS# 2702870, CI MS# 2714582, and CI MS# 2726211) at the facility on 2/26/26.
Complaint Details
Three complaint investigations (CI MS# 2702870, CI MS# 2714582, and CI MS# 2726211) were conducted and no deficiencies were cited, indicating the complaints were not substantiated.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 3
Inspection Report — Sep 30, 2025
Follow-Up
Date: Sep 30, 2025
Visit Reason
From 9/29/25 through 9/30/25, the State Agency (SA) conducted an onsite revisit to the annual survey that was completed on 8/27/25. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 9/22/25. No deficiencies were cited during this revisit.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 24, 2025
Life Safety
Date: Sep 24, 2025
Visit Reason
On 09/24/25 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 08/27/25. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The survey conducted on 08/27/25 revealed the facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Aug 28, 2025
Life Safety
Date: Aug 28, 2025
Visit Reason
The facility underwent a Life Safety Code survey on 08/27/25 to assess compliance with NFPA 101 and related codes.
Findings
The facility failed to maintain a properly functioning fire alarm system as two exit doors did not release and open during testing due to electrical power being cut off during kitchen construction. The issue was corrected later the same day and acknowledged by the surveyor.
Deficiencies (1)
K0345 - Fire Alarm System - Testing and Maintenance. The facility failed to provide a properly maintained fire alarm system as two exit doors did not release and open during testing due to power being cut off during kitchen construction.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 27, 2025
Routine
Date: Aug 27, 2025
Visit Reason
Routine inspection of Ruleville Community Care Center to assess compliance with resident rights, care plans, abuse prevention, environment safety, and medication administration.
Findings
The facility failed to ensure reasonable accommodation of resident needs, timely grievance resolution, safe environment maintenance, protection from abuse, accurate care plan implementation, proper pain management, and accurate medical record keeping. Several residents experienced issues with hydration access, unresolved grievances, unsafe bathroom conditions, verbal abuse, unreported abuse allegations, incomplete care plans, missed medication doses, and lack of restorative nursing services.
Deficiencies (10)
F 0558: The facility failed to provide access to oral hydration for 2 of 96 residents, with water pitchers missing or inaccessible.
F 0565: The facility failed to resolve a grievance for 1 of 8 residents at the resident council meeting, lacking documentation of resolution.
F 0584: The facility failed to maintain a safe, clean environment as a bathroom floor covering was removed leaving stained bare concrete for 1 of 38 residents.
F 0600: The facility failed to protect 1 of 5 residents from verbal abuse by a CNA who told the resident to 'shut up' during care.
F 0609: The facility failed to timely report 3 of 5 alleged abuse violations to the State Survey Agency as required.
F 0656: The facility failed to implement care plans for 6 of 31 residents related to dependent nail care, showers, and pain management.
F 0677: The facility failed to provide basic hygiene care by not ensuring dependent residents received showers and nail care for 5 of 8 residents reviewed.
F 0684: The facility failed to provide restorative nursing services for residents with contractures for 2 of 31 sampled residents, including failure to apply orthotic devices.
F 0697: The facility failed to provide safe, appropriate pain management for 1 of 5 residents by missing fentanyl patch doses causing increased pain and suffering.
F 0842: The facility failed to maintain accurate medical records for 1 of 5 medication reviews as fentanyl patches were documented as given but not administered.
Report Facts
Residents reviewed for hydration: 96
Residents present at resident council meeting: 8
Residents sampled for environment safety: 38
Residents reviewed for abuse and neglect: 5
Alleged abuse violations reviewed: 5
Residents sampled for care plan implementation: 31
Residents reviewed for ADLs: 8
Residents with contractures reviewed: 2
Residents reviewed for medication: 5
Missed fentanyl doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Named in verbal abuse finding involving Resident #3 |
| Licensed Practical Nurse #5 | LPN | Confirmed hydration issues for Residents #38 and #47 |
| Director of Nurses | DON | Confirmed abuse complaints not reported and missed fentanyl doses |
| Administrator | Administrator | Interviewed regarding abuse complaints and medication administration |
| Registered Nurse #2 | RN | Confirmed missed fentanyl doses for Resident #106 |
| Certified Nursing Assistant #6 | CNA | Named in abuse complaints for hurting Anonymous Resident |
| Certified Nursing Assistant #2 | CNA | Named in abuse complaints for hurting Resident #68 |
| Social Services #2 | Social Services | Confirmed grievance and abuse complaint handling |
| Occupational Therapy | OT | Discussed restorative nursing recommendations for orthotics |
| Restorative Licensed Practical Nurse | Restorative LPN | Discussed restorative nursing program and orthotic application |
Inspection Report — Aug 27, 2025
Annual Inspection
Date: Aug 27, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey and Complaint Investigations (CI) MS #472523, CI MS #472548, CI MS #472549, CI MS #472552, CI MS #2576008, and Facility Reported Incident (FRI) MS #2600431 at the facility from 8/25/25 through 8/27/25. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid.
Complaint Details
Complaint Investigations (CI) MS #472523, CI MS #472548, CI MS #472549, CI MS #472552, CI MS #2576008, and Facility Reported Incident (FRI) MS #2600431 were investigated. CI MS #472523, CI MS #2576008, and FRI MS #2600431 were investigated for allegations of abuse, unresolved grievances, and not reporting investigations, resulting in citations for F565, F609, and F610. CI MS #472548, CI MS #472549, and CI MS #472552 were investigated with no deficiencies cited.
Findings
The facility was found not in compliance with multiple requirements including residents' rights, safe environment, abuse prevention, care planning, pain management, and medical record accuracy. Deficiencies were cited for failure to provide reasonable accommodations, resolve grievances, maintain a safe environment, prevent abuse, investigate allegations, implement care plans, provide ADL care, manage pain, and maintain accurate resident records.
Deficiencies (11)
F0558 - Reasonable Accommodations Needs/Preferences. The facility failed to ensure residents’ rights to reasonable accommodation of needs by not providing access to oral hydration for two residents (Resident #38 and Resident #47).
F0565 - Resident/Family Group and Response. The facility failed to resolve a grievance for one resident (Anonymous Resident) present at the resident council meeting as the grievance was not signed by the resident and lacked documentation of resolution.
F0584 - Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a safe, clean, and comfortable environment as evidenced by a bathroom floor covering removed leaving bare concrete with a black stained area around the toilet for Resident #43.
F0600 - Free from Abuse and Neglect. The facility failed to protect a resident's right to be free from verbal abuse for Resident #3, who was told to 'shut up' by a CNA during care.
F0609 - Reporting of Alleged Violations. The facility failed to ensure that all alleged abuse violations were reported to the State Survey Agency as required for Resident #3, Anonymous Resident, and Resident #68.
F0610 - Investigate/Prevent/Correct Alleged Violation. The facility failed to investigate allegations of abuse for Residents #68 and Anonymous Resident and failed to prevent further potential abuse while investigations were in progress.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plans for residents dependent on staff for nail care (Residents #6, #16, #102), showers (Residents #88, #94), and pain management (Resident #106).
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide basic hygiene care by not ensuring dependent residents received showers (Residents #88 and #94) and routine nail care (Residents #6, #16, and #102).
F0684 - Quality of Care. The facility failed to provide restorative nursing services for residents with contractures (Residents #16 and #94) by not implementing orthotic devices and range of motion recommendations.
F0697 - Pain Management. The facility failed to ensure Resident #106 received fentanyl patches as ordered, resulting in missed doses and increased pain.
F0842 - Resident Records - Identifiable Information. The facility failed to maintain accurate medical records for Resident #106 as medications were documented as given when they were not administered.
Report Facts
Deficiencies cited: 11
Inspection Report — Aug 27, 2025
Complaint Investigation
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse and failure to properly resolve grievances and report suspected abuse in the facility.
Complaint Details
The investigation was complaint-driven involving allegations of abuse by Certified Nursing Assistants toward Residents #3, #68, and an Anonymous Resident. The complaints included physical harm and verbal mistreatment. The facility failed to report these allegations to the State Survey Agency and did not conduct timely investigations.
Findings
The facility failed to resolve a grievance for one resident and failed to timely report and investigate alleged abuse involving three residents. Several Certified Nursing Assistants were involved in incidents causing harm or distress to residents, and the facility did not report these to the State Survey Agency as required.
Deficiencies (3)
F 0565: The facility failed to honor the resident's right to organize and participate in resident/family groups by not resolving a grievance for one resident and not documenting resolution or discussion with the resident.
F 0609: The facility failed to timely report suspected abuse and neglect to the State Survey Agency for three residents despite allegations involving Certified Nursing Assistants causing harm or distress.
F 0610: The facility failed to investigate allegations of abuse for two residents and did not complete investigations despite removing involved staff from resident care.
Report Facts
Residents affected: 1
Alleged abuse violations: 5
Residents with abuse allegations: 3
Brief Interview for Mental Status (BIMS) scores: 15
Brief Interview for Mental Status (BIMS) score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in abuse allegation involving Resident #3 |
| Certified Nurse Assistant #6 | Certified Nurse Assistant | Named in abuse allegations involving Anonymous Resident |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Named in abuse allegations involving Anonymous Resident and Resident #68 |
| Certified Nurse Assistant #7 | Certified Nurse Assistant | Assisted CNA #6 on Anonymous Resident during alleged abuse incident |
| Director of Nurses | Director of Nurses | Confirmed complaints and acknowledged failure to report and investigate abuse allegations |
| Former Administrator | Former Administrator | Confirmed receipt of abuse complaint and actions taken but did not report to State Survey Agency |
| ADM | Administrator | Confirmed all allegations of abuse should be reported and investigated |
Inspection Report — Jun 16, 2025
Complaint Investigation
Date: Jun 16, 2025
Visit Reason
The State Agency conducted five Complaint Investigations (CI) at the facility on 6/16/25 for CI MS #28264, CI MS #28429, CI MS #28571, CI MS #29155, and CI MS #29236 and the areas reviewed included Abuse/Neglect, Accidents, Injuries of Unknown Origin, Quality of Care, Psychiatric Services, Environment, and Resident Rights.
Complaint Details
Five complaint investigations were conducted covering Abuse/Neglect, Accidents, Injuries of Unknown Origin, Quality of Care, Psychiatric Services, Environment, and Resident Rights. The facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with the requirements for participation in Medicare and Medicaid with no deficiencies cited.
Report Facts
Complaint Investigations conducted: 5
Inspection Report — Jan 22, 2025
Complaint Investigation
Date: Jan 22, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS # 26668 and CI MS # 26706) at the facility on 1/22/25.
Complaint Details
Complaint Investigation CI MS # 26668 and CI MS # 26706 were conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
Visit Reason
The State Agency conducted three complaint investigations from August 27, 2024 through August 28, 2024 regarding alleged neglect and resident to resident sexual abuse.
Complaint Details
Three complaint investigations were conducted: CI MS #25916 for alleged neglect related to pain and pneumonia concerns, CI MS #26140 for alleged neglect involving restorative care by a specific male employee, and CI MS #26291 for alleged resident to resident sexual abuse. The facility was found in compliance and no deficiencies were cited.
Findings
The facility was found in compliance with the Rules and Regulations for "The Aged and Infirmed" and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 3
Inspection Report — Jul 22, 2024
Complaint Investigation
Date: Jul 22, 2024
Visit Reason
The State Agency conducted a complaint survey, MS CI# 25757 at the facility on 7/22/24. Although there were no deficiencies cited for MS CI# 25757 related to abuse/neglect, quality of care, and hospital transfers, the facility remains out of compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm due to deficiencies cited on the 05/31/24 and 06/25/24 surveys.
Complaint Details
Complaint MS CI# 25757 was investigated related to abuse/neglect, quality of care, and hospital transfers. No deficiencies were cited for this complaint.
Findings
No deficiencies were cited for the complaint investigation MS CI# 25757. The facility remains out of compliance due to prior deficiencies cited on 05/31/24 and 06/25/24 surveys.
Report Facts
Complaint number: 25757
Inspection Report — Jun 25, 2024
Complaint Investigation
Date: Jun 25, 2024
Visit Reason
The inspection was conducted following a complaint alleging that a resident was physically restrained with a sheet tied to a wheelchair without proper physician orders, consent, or assessment.
Complaint Details
The complaint involved an allegation that Resident #1 was physically restrained with a sheet tied to her wheelchair on 6/9/24. The facility investigated but did not report the incident to the State Agency, determining it was done for safety. The Administrator agreed the restraint was inappropriate and should have been reported.
Findings
The facility failed to prevent the use of physical restraints on Resident #1 without physician orders or consent and failed to report the allegation of mistreatment to the State Agency. The resident was found restrained with a sheet tied to the wheelchair and using a mattress with elevated sides and foam wedges without proper orders or assessments.
Deficiencies (2)
F 0604: The facility failed to ensure Resident #1 was free from physical restraints, as she was restrained with a sheet tied to her wheelchair without physician orders, consent, or proper assessment.
F 0609: The facility failed to timely report suspected abuse or mistreatment when Resident #1 was restrained with a sheet tied to her wheelchair, which was considered inappropriate treatment and mistreatment.
Report Facts
Residents reviewed: 6
Residents affected: 1
Date of restraint incident: Jun 9, 2024
Date of investigation: Jun 10, 2024
Date of inspection: Jun 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Assigned nurse for Resident #1 on 6/9/24, denied knowledge of restraint use |
| CNA #1 | Certified Nursing Assistant | Observed Resident #1 restrained with sheet and removed it |
| CNA #2 | Certified Nursing Assistant | Observed Resident #1 restrained with sheet, removed it, and reported nurse's justification |
| CNA #3 | Certified Nursing Assistant | Reported seeing Resident #1 restrained with sheet and informed nurse |
| Director of Nursing | Director of Nursing | Conducted investigation and verified restraint use without orders or consent |
| Unit Manager | Unit Manager | Stated restraints require assessment, physician orders, and consent |
| Administrator | Administrator | Agreed restraint use was inappropriate and should have been reported |
Inspection Report — Jun 25, 2024
Complaint Investigation
Date: Jun 25, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 25499) at the facility on 6/25/24 due to allegations of improper physical restraint and failure to report mistreatment.
Complaint Details
CI MS# 25499 involved allegations that a resident was physically restrained with a sheet tied to a wheelchair and that the facility failed to report this mistreatment. The complaint was substantiated with deficiencies cited.
Findings
The facility was found not in compliance due to failure to prevent physical restraint of a resident with a sheet tied to a wheelchair and failure to report this mistreatment. Two deficiencies were cited related to restraint use and reporting.
Deficiencies (2)
F0604 - The facility failed to prevent a resident from being physically restrained with a sheet tied to the wheelchair and failed to obtain physician orders, consent, and assessment for the use of restraints for one of six residents reviewed.
F0609 - The facility failed to report an allegation of mistreatment when a resident was physically restrained with a sheet tied to the wheelchair for one of six residents reviewed.
Report Facts
Deficiencies cited: 2
Inspection Report — May 31, 2024
Complaint Investigation
Date: May 31, 2024
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #24008, CI MS#24884, CI MS#25027, CI MS#25192, CI MS#25296, and CI MS#25297) from 5/28/24 through 5/31/24. Deficient practice was identified related to CI MS #25192 concerning allegations of abuse and neglect, including an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) beginning 11/17/23, resulting in the physical assault and death of a resident on 5/22/24.
Complaint Details
CI MS#25192 involved allegations of abuse and neglect related to Resident #1's behaviors, including getting into other residents' beds, which resulted in the physical assault and death of Resident #2 on 5/22/24. The complaint was substantiated with deficiencies cited.
Findings
The facility was found not in compliance due to failure to identify and intervene in resident behavioral issues, resulting in the death of Resident #2 when Resident #1 laid on top of him. The facility failed to revise care plans, provide adequate supervision, and implement appropriate behavioral interventions for Resident #1 from 11/17/23 through 5/22/24. The Immediate Jeopardy was removed on 5/31/24 after corrective actions were implemented.
Deficiencies (4)
F0600 - Free from Abuse and Neglect. The facility failed to protect one resident from neglect and abuse, resulting in Resident #2's death when Resident #1 laid on top of him on 5/22/24. The facility did not identify roommate incompatibility or provide appropriate behavioral interventions from 11/17/23 to 5/22/24.
F0657 - Care Plan Timing and Revision. The facility failed to revise Resident #1's care plan to include interventions for his behavior of getting into other residents' beds, which contributed to Resident #2's death on 5/22/24.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision and monitoring for Resident #1, who had behavioral issues of getting into other residents' beds, resulting in the physical assault and death of Resident #2 on 5/22/24.
F0742 - Treatment/Services Mental/Psychosocial Concerns. The facility failed to recognize and provide appropriate person-centered behavioral interventions for Resident #1 from 11/17/23 through 5/22/24, resulting in Resident #2's death and placing other residents at risk.
Report Facts
Deficiencies cited: 9
Complaint investigations: 6
Residents: 108
Licensed beds: 111
Residents interviewed: 28
Residents in resident council: 21
Inspection Report — Nov 30, 2023
Annual Inspection
Date: Nov 30, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, incomplete PASRR referrals for residents with mental disorders, inadequate care plan implementation, unsafe resident transfers, improper gastrostomy tube care, lack of monitoring for medication side effects, unsecured controlled medication storage, and unclean ice machines.
Deficiencies (10)
F 0550: The facility failed to maintain a dining experience that promotes dignity as staff were observed standing while feeding a resident instead of sitting at eye level.
F 0644: The facility failed to submit a change in status referral for a Level II PASRR resident review related to a new mental disorder diagnosis for one resident.
F 0645: The facility failed to complete a Level II PASRR screening for a resident with an identified mental disorder prior to admission.
F 0656: The facility failed to develop and implement complete care plans for monitoring behaviors and side effects of psychotropic and anticoagulant medications and for gastrostomy tube care for two residents.
F 0689: The facility failed to prevent potential accidents by not utilizing appropriate staff when transferring a resident, leaving the resident suspended in a lift unattended.
F 0693: The facility failed to ensure a resident with a gastrostomy tube received care to prevent complications by not checking tube placement prior to medication administration.
F 0757: The facility failed to monitor a resident for medication side effects related to anticoagulant use, missing documentation for bleeding and bruising monitoring.
F 0758: The facility failed to ensure behavioral interventions and side effect monitoring for psychotropic medications were implemented and documented for a resident.
F 0761: The facility failed to ensure controlled medications were stored in secure locked containers, with two narcotic lock boxes either unlocked or not secured to the refrigerator.
F 0812: The facility failed to maintain clean ice machines, with black and yellow mucus buildup observed inside two ice machines used by residents.
Report Facts
Residents reviewed for care plans: 23
Residents reviewed for PASRR: 6
Residents reviewed for PASRR: 5
Lorazapam single dose vials: 12
Lorazapam single dose vials: 17
Lorazapam multidose vials: 1
Lorazapam multidose vials: 2
Residents using ice: 96
Total residents in facility: 105
Inspection Report — Nov 30, 2023
Annual Inspection
Date: Nov 30, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey and a complaint investigation (CI) MS #23397 at the facility from 11/28/23 through 11/30/23. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation and cited regulatory deficiencies. The SA determined the facility was in compliance for CI MS #23397 and no deficiencies were cited related to the complaint.
Complaint Details
Complaint investigation CI MS #23397 was conducted concurrently but no deficiencies were cited related to the complaint and the facility was found in compliance for this complaint.
Findings
The facility was found not in compliance with several Medicare and Medicaid participation requirements, citing deficiencies in resident rights, PASARR coordination, care planning, accident prevention, tube feeding management, medication regimen, psychotropic medication use, drug storage, and food safety. No deficiencies were cited related to the complaint investigation.
Deficiencies (10)
F0550 - Resident rights were not maintained as staff failed to promote dignity by standing while feeding residents requiring assistance.
F0644 - The facility failed to submit a change in status referral for a Level II PASARR review for a resident with a new mental disorder diagnosis.
F0645 - The facility failed to complete a Level II PASARR for a resident with an identified mental disorder prior to admission.
F0656 - The facility failed to implement a care plan for monitoring side effects of anticoagulants and psychotropic medications and failed to fully develop a care plan for gastrostomy tube management.
F0689 - The facility failed to prevent potential accidents by not utilizing appropriate staff when transferring a resident requiring a total body lift.
F0693 - The facility failed to ensure a resident with a gastrostomy tube received care to prevent complications by not checking tube placement prior to medication administration.
F0757 - The facility failed to monitor a resident for medication side effects related to anticoagulant use.
F0758 - The facility failed to ensure a resident received behavioral interventions or side effect monitoring with the use of psychotropic medications.
F0761 - The facility failed to ensure controlled medications were stored in a secure locked container in two narcotic storage containers.
F0812 - The facility failed to maintain clean ice machines, with black mucus and mineral buildup observed inside two ice machines used by residents.
Report Facts
Deficiencies cited: 10
Inspection Report — Nov 29, 2023
Life Safety
Date: Nov 29, 2023
Visit Reason
The facility was surveyed for 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. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Oct 24, 2023
Complaint Investigation
Date: Oct 24, 2023
Visit Reason
On 10/24/23 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 09/14/23. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 09/14/23; the facility was found in compliance after the desk review on 10/24/23 with no deficiencies cited.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 10/20/23. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Oct 3, 2023
Complaint Investigation
Date: Oct 3, 2023
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #22910 and CI MS #22888) at the facility from 10/2/23 through 10/3/23.
Complaint Details
Two complaint investigations (CI MS #22910 and CI MS #22888) were conducted and found no deficiencies; the facility was in compliance for these complaints.
Findings
The facility was found in compliance with Medicare and Medicaid requirements during these complaint investigations, and no deficiencies were cited. However, the facility remains out of compliance due to deficiencies cited on the 9/14/2023 survey.
Report Facts
Complaint Investigations: 2
Inspection Report — Sep 14, 2023
Complaint Investigation
Date: Sep 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged employee-to-resident abuse incident involving a Certified Nursing Assistant (CNA) pouring water on a resident.
Complaint Details
The complaint was substantiated. The investigation revealed that CNA #1 poured water on Resident #1 after the resident rolled over the CNA's foot with a wheelchair. The CNA was suspended and subsequently resigned. The incident was reported to the Police Department, Survey Agency, Attorney General's office, and State Ombudsman office.
Findings
The facility failed to ensure a resident was free from abuse when a CNA poured water on a resident in retaliation for the resident rolling over the CNA's foot with a wheelchair. The facility investigation confirmed the abuse and reported the incident to local authorities and relevant agencies.
Deficiencies (1)
F 0600: The facility failed to protect residents from abuse when a CNA poured water on a resident in retaliation for the resident rolling over the CNA's foot with a wheelchair.
Inspection Report — Sep 14, 2023
Complaint Investigation
Date: Sep 14, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI MS#22653) at the facility on 9/14/23. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid Services due to failure to prevent abuse.
Complaint Details
CI MS#22653 involved an allegation of abuse where a CNA threw water on a resident. The complaint was substantiated with deficiencies cited.
Findings
The facility failed to ensure a resident was free from abuse when a Certified Nursing Assistant (CNA) threw water on a resident. The incident was confirmed by multiple staff and resident interviews and facility investigation.
Deficiencies (1)
F0600 - The facility failed to ensure a resident was free from abuse when a Certified Nursing Assistant (CNA) threw water on a resident. The CNA was suspended and subsequently resigned. The facility conducted staff in-services and initiated monitoring to prevent recurrence.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 1, 2023
Complaint Investigation
Date: Aug 1, 2023
Visit Reason
On 08/01/23 the State Agency conducted a desk review of information related to the complaint survey completed on 06/14/23. The facility confirmed corrective measures were in place and compliance was sustained.
Complaint Details
CI MS#26995 complaint survey completed on 06/14/23 was reviewed and found to be corrected and sustained; no deficiencies cited.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 07/25/23. No deficiencies were cited.
Report Facts
Deficiencies cited: 0
Inspection Report — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
The State Agency (SA) conducted a complaint investigation, CI MS# 21622, at the facility from 6/13/23 through 6/14/23. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid Services.
Complaint Details
CI MS# 21622: The complaint alleged failure to secure a resident with proper vehicle restraints during transport and failure to properly monitor the resident during transport. Deficiency F0689 was cited, substantiating the complaint.
Findings
F0689 - The facility failed to promote safety during transport by not using a vehicle safety lap restraint on a resident, failed to properly monitor the resident during transport, and failed to prevent a resident from falling out of a motorized wheelchair during transport in the facility van.
Deficiencies (1)
F0689 - The facility failed to promote safety during transport by not using a vehicle safety lap restraint on a resident, failed to properly monitor the resident during transport, and failed to prevent a resident from falling out of a motorized wheelchair during transport in the facility van.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 14, 2023
Date: Jun 14, 2023
Visit Reason
The inspection was conducted to investigate a safety incident involving a resident who fell out of a motorized wheelchair during transport in the nursing facility van.
Findings
The facility failed to ensure the resident was properly secured with a vehicle safety lap restraint during transport, failed to provide adequate monitoring, and did not adhere to facility policy, resulting in a resident falling out of his motorized wheelchair and sustaining pain.
Deficiencies (1)
F 0689: The facility failed to promote safety by not using a vehicle safety lap restraint on a resident during transport, failing to provide proper monitoring, and failing to prevent a resident from falling out of a motorized wheelchair in the transport van.
Report Facts
Incident date: Jul 13, 2022
Assessment Reference Date: Jun 5, 2023
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Responsible for transporting Resident #1 and failing to secure him with the van lap seat belt |
| CNA #2 | Certified Nursing Assistant | Support staff during transport, not seated with Resident #1 to monitor him |
| RN #1 | Registered Nurse | Prepared the incident report and was informed of the fall |
| Director of Nursing | Director of Nursing | Interviewed and confirmed lack of awareness of broken seat belt and failure to secure Resident #1 |
| Administrator | Administrator | Confirmed failure to secure Resident #1 and inadequate monitoring during transport |
Inspection Report — Apr 18, 2023
Complaint Investigation
Date: Apr 18, 2023
Visit Reason
The State Agency conducted a complaint survey, MS #21319 on 4/18/23. During the survey the SA investigated complaint MS #21319 for staffing and physical environment.
Complaint Details
Complaint MS #21319 was investigated for staffing and physical environment and was determined to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Mar 27, 2023
Complaint Investigation
Date: Mar 27, 2023
Visit Reason
The State Agency conducted a complaint survey, MS #21004, on 3/27/23 regarding Unnecessary Medications, Sexual Abuse, Emotional-Behavioral Health, Activities of Daily Living and Misappropriation of Property for Resident #1.
Complaint Details
Complaint MS #21004 involved allegations of Unnecessary Medications, Sexual Abuse, Emotional-Behavioral Health, Activities of Daily Living and Misappropriation of Property for Resident #1 and was found to have no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm after investigation of complaint MS #21004 with no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Mar 27, 2023
Complaint Investigation
Date: Mar 27, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 21004) at the facility on 3/27/23.
Complaint Details
Complaint number CI MS# 21004 involved allegations of Unnecessary Medications, Sexual Abuse, Emotional-Behavioral Health, Activities of Daily Living, and Misappropriation of Property for Resident #1. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid Services requirements. No deficiencies were cited related to Unnecessary Medications, Sexual Abuse, Emotional-Behavioral Health, Activities of Daily Living, and Misappropriation of Property for Resident #1.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 28, 2023
Follow-Up
Date: Feb 28, 2023
Visit Reason
On 02/28/23 the State Agency (SA) conducted a revisit for the 2567 dated 01/21/2023 in which four (4) Immediate Jeopardies were cited at F600, F623, F660, and F835. The onsite revisit determined that the facility had corrected the non-compliance as of 02/19/2023 and was placed back in compliance.
Findings
On 02/27/23-02/28/23 the SA determined that the facility was in compliance with the standards for participation in Medicare and Medicaid. There were no deficiencies cited on 02/28/23.
Report Facts
Deficiencies cited: 4
Inspection Report — Feb 27, 2023
Complaint Investigation
Date: Feb 27, 2023
Visit Reason
The State Agency conducted an onsite complaint investigation, CI MS #20808 for an alleged violation of a Residents Rights/Verbal Abuse.
Complaint Details
CI MS #20808 for an alleged violation of a Residents Rights/Verbal Abuse. The complaint was investigated and no deficiencies were cited.
Findings
The State Agency determined that on 02/27/23 the facility was in compliance with the standards for participation in Medicare and Medicaid and no deficiencies were cited for CI MS #20808. The facility remains Out of Compliance due to deficiencies cited on the 1/21/2023 survey.
Inspection Report — Jan 21, 2023
Complaint Investigation
Date: Jan 21, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS CI #20343, CI MS #20374, CI MS #20285, CI MS #20319, and CI MS #20488 at the facility from 1/9/23 to 1/21/23. During the survey, the SA determined that the facility was not in compliance with the requirements for participation in Medicare and Medicaid. An extended survey was completed, and the following deficiencies were cited for CI MS #20319 and CI MS #20343: F600, F623, F660, F835 at an Immediate Jeopardy (IJ) level for resident-to-resident abuse, discharge rights, facility administration, and discharge planning. The SA found no evidence of deficient practice for CI MS #20285, CI MS 20374 and CI MS #20488.
Complaint Details
CI MS #20319 and CI MS #20343 involved Immediate Jeopardy findings for resident-to-resident abuse, discharge rights, facility administration, and discharge planning. The Immediate Jeopardy was removed after the facility submitted an acceptable Removal Plan and corrective actions were validated.
Findings
The facility was found not in compliance due to failure to protect residents from resident-to-resident abuse, failure to notify the Resident Representative of discharge, failure to ensure safe discharge with medication instructions, and failure to administer the facility effectively to maintain resident well-being. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (4)
F0600 - The facility failed to protect three residents from resident-to-resident physical abuse by Resident #1, who assaulted Resident #2 and Resident #8 causing injury. Resident #1 was discharged without proper notification to the Resident Representative and was left unattended at the Representative's locked home with medications.
F0623 - The facility failed to notify the Resident Representative of Resident #1's discharge and failed to provide the reasons in writing and in a manner they could understand. Resident #1 was discharged against medical advice and left unattended at the Representative's home.
F0660 - The facility failed to ensure Resident #1 had available caregiver support and a safe post-discharge destination, failed to notify the Resident Representative of discharge, and failed to provide instructions on post-discharge care and medications. Resident #1 was left unattended at the Representative's home with medications and no discharge instructions.
F0835 - The facility was not administered in a manner that enabled it to use resources effectively and efficiently to maintain the highest practicable well-being of residents. Resident #1 was discharged without notifying the Resident Representative and was left alone outside the Representative's locked home with medications and no discharge instructions.
Report Facts
Deficiencies cited: 4
Licensed beds: 111
Inspection Report — Oct 27, 2022
Complaint Investigation
Date: Oct 27, 2022
Visit Reason
The State Agency conducted a complaint survey MS #19687 and MS #19611 on 10/27/22. The SA did not substantiate the complaint of MS#19687 with allegations regarding transfer rights and MS#19611 for Responsible Party notification, Resident Rights and physical environment.
Complaint Details
Complaint MS #19687 regarding transfer rights and MS #19611 regarding Responsible Party notification, Resident Rights and physical environment were not substantiated; no deficiencies cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. There were no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 16, 2022
Annual Inspection
Date: Aug 16, 2022
Visit Reason
On 08/16/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 07/14/22. 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.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 08/10/22. No deficiencies were cited in this desk review.
Inspection Report — Aug 10, 2022
Life Safety
Date: Aug 10, 2022
Visit Reason
On 08/10/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 07/12/22. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The SA is recommending that your facility be placed back in compliance effective 08/09/22. No deficiencies were cited in this desk review.
Inspection Report — Jul 14, 2022
Routine
Date: Jul 14, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to maintain a safe and clean environment as evidenced by dirty floors with sticky residue in resident rooms and loose, hazardous metal corner molding with crumbling sheetrock in another room. These conditions persisted despite observations over several days and staff interviews confirming lack of appropriate policies and cleaning.
Deficiencies (2)
F 0584: The facility failed to provide a safe, clean, and homelike environment as evidenced by dirty floors with sticky residue approximately 14 inches in diameter in room E 2 that was not cleaned over multiple days. The buildup of black residue was present around the bathroom door base.
F 0584: The facility failed to maintain building repairs as evidenced by loose metal corner molding approximately 2 to 4 feet long in room E 20 that was disconnected from the wall with crumbling sheetrock behind it, posing a potential hazard to residents.
Report Facts
Rooms observed: 64
Length of metal molding: 4
Diameter of sticky residue spot: 14
Pieces of sheetrock: 4
Inspection Report — Jul 14, 2022
Annual Inspection
Date: Jul 14, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey and a complaint survey for MS #18682, MS #18842, and MS #19359 at the facility from 7/11/22 through 7/14/22. During the survey, the SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid. The SA substantiated MS #18842 and MS #19359 and cited F584 related to safe and clean environment. The SA did not substantiate MS #18682.
Complaint Details
Complaint surveys for MS #18682, MS #18842, and MS #19359 were conducted. The SA substantiated MS #18842 and MS #19359 with deficiencies cited (F584). MS #18682 was not substantiated.
Findings
F0584 - The facility failed to provide a safe and clean homelike environment as evidenced by dirty floors and loose metal corner molding in resident rooms E2 and E20. Observations revealed crumbling sheetrock behind loose molding, sticky residue buildup on floors, and lack of a specific policy regarding building repair.
Deficiencies (1)
F0584 - The facility failed to provide a safe and clean homelike environment as evidenced by dirty floors and loose metal corner molding in resident rooms E2 and E20, including crumbling sheetrock and sticky residue buildup on floors.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 12, 2022
Life Safety
Date: Jul 12, 2022
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility failed to provide documentation of an annual fire alarm inspection and sensitivity testing for the calendar year 2021. This deficiency affected the entire facility and was acknowledged by the Administrator and Maintenance Supervisor.
Deficiencies (1)
K0345 - Fire Alarm System - Testing and Maintenance. The facility failed to provide annual inspection and sensitivity testing documentation for the fire alarm system for the calendar year 2021.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 12, 2022
Date: Jul 12, 2022
Visit Reason
The Mississippi State Department of Health conducted a survey on 07/12/2022 to assess compliance with Life Safety Code requirements.
Findings
The facility failed to provide documentation of an annual fire alarm inspection and sensitivity testing for the calendar year 2021. The deficiency affected the entire facility and was acknowledged by the Administrator and Maintenance Supervisor.
Deficiencies (1)
M1245 - The facility failed to provide the Fire Alarm annual inspection and sensitivity testing documentation for the calendar year 2021, affecting the entire facility.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 17, 2022
Routine
Date: Jan 17, 2022
Visit Reason
The facility was surveyed for COVID-19 reporting compliance as required by regulation.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. This failure had the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 6, 2022
Complaint Investigation
Date: Jan 6, 2022
Visit Reason
A complaint investigation (CI) #18366 was conducted on 1/6/22 related to an incident filed by the facility regarding the death of a resident.
Complaint Details
CI #18366 related to an incident filed by the facility regarding the death of a resident was unsubstantiated with no deficiencies cited.
Findings
The incident was unsubstantiated with no deficiencies cited. However, the facility remains out of compliance due to deficiencies cited on CI MS #18122 and CI MS #18231.
Inspection Report — Dec 7, 2021
Complaint Investigation
Date: Dec 7, 2021
Visit Reason
A Compliant Investigation (CI) for CI #18231 and CI#18122 on 12/7/21. CI #18231 was filed by the family with allegations of Quality of Care and the RP was not notified with changes in condition. CI#18122 was reported by another medical facility with allegations of abuse.
Complaint Details
Complaint Investigation CI #18231 and CI#18122 were conducted. CI #18231 involved allegations of Quality of Care and failure to notify RP of changes in condition. CI#18122 involved allegations of abuse. The complaints were unsubstantiated except for one deficiency cited for failure to report to licensure and certification for CI#18122.
Findings
One deficiency was cited for failure to report an allegation of abuse to licensure and certification in a timely manner. The facility failed to notify state agencies within the required two-hour timeframe regarding an allegation of sexual abuse involving Resident #1.
Deficiencies (1)
F0609 - Reporting of Alleged Violations. The facility failed to report to licensure and certification an allegation of abuse regarding Resident #1 within the required timeframe.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 1, 2021
Complaint Investigation
Date: Jul 1, 2021
Visit Reason
The State Agency conducted a complaint survey, CI MS# 17845 on 7/1/21.
Complaint Details
Complaint CI MS# 17845 alleged Quality of Care related to improper incontinence care and Misappropriation of Property related to resident personal items, clothing, and jewelry. The complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — Feb 9, 2021
Routine
Date: Feb 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and Complaint Investigations (CI) MS #17528, CI MS #17485, CI #17094, CI #17213, CI #16974, and CI #16808 were conducted by the State Agency from 2/2/21 through 2/9/21.
Complaint Details
Complaint investigations CI MS #17528, CI MS #17485, CI MS #17094, CI MS #17213, CI MS #16974, and CI MS #16808 were not substantiated for various allegations including resident neglect, quality of care, resident assessment, and resident abuse.
Findings
The facility was found to be in compliance with 42 CFR 483.30 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. None of the complaint investigations were substantiated.
Report Facts
Complaint investigations: 6
Inspection Report — Feb 9, 2021
Complaint Investigation
Date: Feb 9, 2021
Visit Reason
The State Agency conducted Complaint Investigations (CI) MS #17528, CI MS #17485, CI #17094, CI #17213, CI #16974, and CI #16808 from 2/2/21 through 2/9/21.
Complaint Details
Complaint Investigations CI MS #17528, CI MS #17485, CI #17094, CI MS #17213, CI MS #16974, and CI MS #16808 were all not substantiated for various allegations including resident neglect, quality of care, resident assessment, resident abuse, and injury of unknown origin.
Findings
The facility was found to be in compliance with the Minimum Standards for the Aged or Infirm. None of the complaint investigations were substantiated.
Report Facts
Complaint Investigations conducted: 6
Inspection Report — Jan 13, 2021
Routine
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 1/13/21.
Findings
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.
Inspection Report — Jan 13, 2021
Routine
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 1/13/21.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Sep 25, 2020
Routine
Date: Sep 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 08/04/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 24, 2020
Routine
Date: Aug 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/24/20.
Findings
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.
Inspection Report — Aug 4, 2020
Routine
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 08/04/2020. The facility was found to not be in compliance with infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Findings
F0880 - Infection Prevention & Control. The facility failed to prevent the potential spread of infection as staff did not perform hand hygiene when entering and exiting resident rooms during observed care of Resident #1.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to prevent the potential spread of infection as staff did not perform hand hygiene when entering and exiting resident rooms during observed care of Resident #1.
Report Facts
Deficiencies cited: 1
Inspection Report — May 29, 2020
Routine
Date: May 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/29/20.
Findings
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.
Inspection Report — Jan 22, 2020
Complaint Investigation
Date: Jan 22, 2020
Visit Reason
The State Survey Agency (SA) conducted a complaint investigation on 1/22/20.
Complaint Details
Complaint investigation CI MS #15925 & 16551 was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Inspection Report — Dec 20, 2019
Complaint Investigation
Date: Dec 20, 2019
Visit Reason
The State Agency conducted two complaint investigations (CI MS #16231 and CI MS #16451) from 12/18/19 through 12/20/19. The complaints involved concerns such as bruising, weight loss, clothing issues, staff identification, pressure sores, abuse allegations, and inappropriate transfer.
Complaint Details
Two complaints were investigated: CI MS #16231 involved multiple concerns for Resident #1 including bruising, weight loss, clothing issues, and pressure sores, which were not substantiated. CI MS #16451 involved alleged physical abuse and inappropriate transfer of a different Resident #1, which was also not substantiated. However, a dignity issue was cited under F550.
Findings
The facility was found not in compliance due to a dignity concern during transfer of Resident #5 using a stand-up mechanical lift. No other deficiencies were cited and the other complaints were not substantiated.
Deficiencies (1)
F0550 - Resident rights were not maintained as the facility failed to maintain dignity for one resident during transfer using a lift, where the resident was partially exposed and the door to the room would not stay closed for privacy.
Report Facts
Deficiencies cited: 1
Inspection Report — May 2, 2019
Annual Inspection
Date: May 2, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification along with complaint investigations, MS #15873 and MS #15850, from 4/29/19 to 5/2/19. During the survey, the SA determined the facility was not in compliance with the requirements of participation for Medicare and Medicaid. The SA did not substantiate MS #15850 and MS #15873 for allegations related to Quality of Care.
Complaint Details
Complaint investigations MS #15873 and MS #15850 were conducted during the survey. The SA did not substantiate MS #15850 and MS #15873 for allegations related to Quality of Care.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements with deficiencies cited at F578, F623, F641, and F656. The facility failed to accurately document advance directives, notify the State Ombudsman of hospital transfers, accurately code Minimum Data Set assessments, and revise comprehensive care plans to reflect changes in resident condition.
Deficiencies (4)
F0578 - The facility failed to accurately document a resident's choice related to Advance Directives for one of 26 residents reviewed for code status, specifically Resident #102 whose orders conflicted between DNR and Full Code.
F0623 - The facility failed to notify the State Ombudsman regarding hospital transfers for four residents reviewed (Residents #96, #73, #63, and #88).
F0641 - The facility failed to accurately code the Minimum Data Set (MDS) assessments for five residents (#107, #88, #5, #96, and #64), including failure to document serious mental illness and inaccurate coding of medications and weight changes.
F0656 - The facility failed to revise the comprehensive care plan to reflect the change of limited range of motion (ROM) for Resident #5, despite a fracture and use of a brace.
Report Facts
Deficiencies cited: 4
8 CMS Surveys
CMS Survey — Jun 14, 2023
Jun 14, 2023
CMS Survey — Sep 14, 2023
Sep 14, 2023
CMS Survey — May 31, 2024
May 31, 2024
CMS Survey — Jun 25, 2024
Jun 25, 2024
CMS Survey — Aug 27, 2025
Aug 27, 2025
CMS Survey — Jul 14, 2022
Jul 14, 2022
CMS Survey — Nov 30, 2023
Nov 30, 2023
CMS Survey — Aug 27, 2025
Aug 27, 2025
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