Inspection Reports for
Sardis Community Nursing Home
613 East Lee Street, Sardis, MS, 38666
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Inspection Report — Dec 23, 2025
Complaint Investigation CMS
Date: Dec 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of abuse involving Resident #1 by Nurse Aide #1 on 2025-09-17.
Complaint Details
The complaint investigation involved an allegation that Nurse Aide #1 abused Resident #1 on 2025-09-17 by pulling him from his wheelchair onto the floor, spraying him with an aerosol disinfectant, verbally berating him, and throwing his belongings away. Multiple staff and resident interviews and witness statements supported the occurrence of abuse. The Administrator concluded the abuse was unsubstantiated due to inability to prove intent, but acknowledged this decision was not supported by the totality of evidence.
Findings
The facility failed to ensure Resident #1 was free from abuse when Nurse Aide #1 pulled the resident from his wheelchair onto the floor, verbally berated him, sprayed him with an aerosol substance, and threw his belongings into the garbage. The facility also failed to thoroughly investigate the abuse allegation, excluding key witness statements and concluding the abuse was unsubstantiated due to lack of proof of intent.
Deficiencies (2)
F 0600: The facility failed to protect Resident #1 from abuse when Nurse Aide #1 pulled him onto the floor, sprayed him with an aerosol disinfectant, verbally berated him, and threw his belongings into the garbage can. This caused actual psychosocial harm including fear and distress.
F 0610: The facility failed to thoroughly investigate an allegation of abuse involving Resident #1, excluding witness statements and concluding the allegation was unsubstantiated despite evidence indicating abuse occurred.
Report Facts
Residents reviewed: 5
Residents affected: 1
BIMS score: 12
Days to certification exam: 120
Inspection Report — Jul 1, 2025
Routine CMS
Date: Jul 1, 2025
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain a homelike environment, inaccurate resident assessments, incomplete care plans, failure to provide required assistance with activities of daily living, inadequate monitoring of anticoagulant medication effects, incomplete wound treatment documentation, and improper infection control practices related to hand hygiene.
Deficiencies (7)
F 0584: The facility failed to provide a homelike environment for one resident due to missing paint in the resident's room that was not repaired.
F 0641: The facility failed to accurately code an admission Minimum Data Set assessment for one resident by incorrectly coding bed rails as restraints.
F 0656: The facility failed to develop a comprehensive care plan for a resident on anticoagulant therapy and failed to implement an ADL care plan for another resident.
F 0677: The facility failed to provide bathing assistance as required for one resident, resulting in poor hygiene.
F 0757: The facility failed to monitor adverse effects of anticoagulant medication for one resident, lacking protocols to detect bleeding risks.
F 0842: The facility failed to document wound treatments for a resident with a Stage 3 pressure ulcer on multiple days over several months.
F 0880: The facility failed to ensure proper hand hygiene during medication administration and wound care, risking infection transmission.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents reviewed: 26
Residents reviewed: 18
Residents reviewed: 5
Missing wound treatment documentation days: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Failed to perform hand hygiene before medication administration |
| Registered Nurse #2 | RN | Failed to change gloves and perform hand hygiene during wound care |
| Licensed Practical Nurse #2 | LPN | Reported no monitoring orders for anticoagulant medication side effects |
| Licensed Practical Nurse #3 | LPN | Reported occasional failure to document wound treatments |
| Director of Nursing | DON | Acknowledged deficiencies and emphasized expectations for care and documentation |
| Minimum Data Set Coordinator | MDS Coordinator | Acknowledged inaccurate MDS coding and lack of monitoring protocols |
Inspection Report — Jul 23, 2024
Complaint Investigation CMS
Date: Jul 23, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to complete and submit a Discharge Tracking Minimum Data Set (MDS) assessment, failure to implement individualized care plans including oral and nail care, and failure to provide trauma informed care for residents with PTSD.
Complaint Details
The complaint investigation substantiated failures in completing required MDS assessments, implementing individualized care plans, providing daily oral and nail care, and conducting trauma informed care assessments for residents with specific needs.
Findings
The facility failed to complete and submit a discharge tracking MDS assessment for a transferred resident, failed to implement care plans addressing oral and nail care and individualized behavioral needs for residents, and failed to complete a trauma informed care assessment for a resident diagnosed with PTSD. These failures were confirmed through record reviews, observations, and staff interviews.
Deficiencies (4)
F0640: The facility failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) assessment for Resident #38 after transfer to an acute care facility.
F0656: The facility failed to develop and implement a complete care plan for nail and oral care for Resident #31 and failed to develop an individualized care plan addressing PTSD triggers for Resident #37.
F0677: The facility failed to provide daily oral care and nail care for Resident #31, resulting in yellow buildup on teeth and debris under fingernails.
F0699: The facility failed to complete a Trauma Informed Care Assessment for Resident #37 diagnosed with PTSD, missing identification of symptoms and triggers.
Report Facts
Residents reviewed: 16
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed failures in MDS discharge tracking assessment and care plan implementation |
| Licensed Practical Nurse #1 | LPN | Observed and confirmed oral and nail care deficiencies for Resident #31 |
| Licensed Practical Nurse #2 | LPN | Confirmed awareness of Resident #37's PTSD diagnosis and care needs |
| Social Services #1 | Social Services (SS) | Provided information on Resident #37's trauma history and social assessment status |
| Minimum Data Set Nurse | MDS Nurse | Confirmed missing MDS discharge tracking assessment and care plan deficiencies |
Inspection Report — Jun 8, 2023
CMS
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards including medication administration, use of restraints, pharmaceutical services, and infection prevention and control at Sardis Community Nursing Home.
Findings
The facility failed to notify the physician and pharmacy about the lack of medication Clopidogrel for Resident #18, resulting in the medication not being administered for several days. The facility also failed to ensure Resident #42 was free from physical restraints, as she was found with a winged mattress and full side rails without physician orders or consent. Additionally, the facility did not administer a required second step TB skin test to one employee, indicating a lapse in infection control procedures.
Deficiencies (5)
F 0580: The facility failed to notify the physician of the failure to obtain and administer Clopidogrel for Resident #18 as ordered, placing the resident at risk for circulation concerns and blood clots.
F 0604: The facility failed to ensure Resident #42 was free from physical restraints, as she was found with a winged mattress and full side rails without physician orders, assessment, or consent.
F 0658: The facility failed to provide pharmaceutical services meeting professional standards by signing off Clopidogrel as administered for Resident #18 on four days when the medication was not dispensed or given.
F 0755: The facility failed to meet pharmaceutical service requirements by not timely implementing physician orders and failing to notify pharmacy and physician about the missing Clopidogrel medication for Resident #18.
F 0880: The facility failed to establish and maintain an infection prevention and control program by not administering a required second step Tuberculin skin test to one employee prior to working in the facility.
Report Facts
Medications reviewed: 16
Residents reviewed: 59
Employees reviewed: 10
Days medication signed off as given: 4
Side rails length: 54
BIMS score: 7
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to notify physician and pharmacy about missing Clopidogrel and signed medication as given when not administered |
| LPN #3 | Licensed Practical Nurse | Signed off Clopidogrel as administered when medication was not given and failed to notify physician or pharmacy |
| Director of Nursing (DON) | Director of Nursing | Unaware of missing medication initially; confirmed risks to Resident #18 and verified restraint use on Resident #42 |
| Administrator | Facility Administrator | Confirmed failures in medication administration and notification processes |
| LPN #1 | Licensed Practical Nurse | Provided information on restraint use and facility policy |
| Minimum Data Set Nurse (MDS Nurse) | MDS Nurse | Spoke with pharmacy regarding medication order and provided cognitive status information |
| Registered Nurse (RN) #1 | Registered Nurse | Confirmed policy on notifying physician when medication is unavailable |
| Licensed Practical Nurse (LPN) Assessment Nurse | LPN Assessment Nurse | Provided information on TB skin testing responsibilities and procedures |
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