Inspection Reports for
Senatobia Healthcare and Rehab

Complaint survey completed on 5/13/26; the facility was found to have corrected the deficient practice and sustained compliance; no deficiencies cited.

The State Agency is recommending that the facility be placed back in compliance effective 06/19/26. No deficiencies were cited in this document.

Complaint investigation CI MS #3007291 was conducted due to concerns about medication administration errors and timeliness. Deficiencies were substantiated with citations for medication error rate and significant medication errors.

The facility was found not in compliance due to a medication error rate of 100% with significant medication errors related to late administration of medications for four residents. The facility failed to ensure medications were administered according to physician orders and accepted standards of practice.

CI MS #2967639 was investigated for accidents and nursing services. Deficiency M640 was cited.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. The facility failed to ensure the environment remained free of accident hazards by not investigating an initial fall, not implementing interventions to prevent recurrence, and not maintaining a resident's bed in a low position.

CI MS #2967639 was investigated for accidents and nursing services. Deficiencies were cited related to care plan revision, accident hazards, and bed rail use.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in care plan timing and revision, accident hazards and supervision, and bed rail use for one resident.

Complaint Investigations CI MS# 2727256 and CI MS# 2966530 were conducted; the facility was found in compliance with no deficiencies cited.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and there were no deficiencies cited.

CI MS#26995 complaint investigation was reviewed and found to be substantiated with no deficiencies cited as the facility was found in compliance.

The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 12/15/25.

Complaint numbers MS CI# 2655634 and MS CI# 2662668 were investigated related to Resident Rights and Quality of Care; the facility was found in compliance with no deficiencies cited during this survey.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm during this complaint investigation. However, the facility remains out of compliance due to deficiencies cited on the 10/27/25 survey.

The complaint was substantiated based on bank transactions and surveillance footage showing the former Assistant Housekeeping Supervisor withdrawing funds from the resident's account. Law enforcement and the Attorney General's office were involved in the investigation.

The facility substantiated the allegation that a former Assistant Housekeeping Supervisor misappropriated Resident #1's debit card and withdrew over $8,200 through multiple unauthorized transactions. The resident was cognitively intact and the exploitation was confirmed by surveillance footage and bank records.

Incident #2640482 involved misappropriation of personal funds by a former Assistant Housekeeping Supervisor who used Resident #1’s debit card to withdraw over $8,200. The allegation was substantiated based on surveillance footage and bank transactions.

F0602 - The facility failed to ensure a resident’s right to be free from exploitation and misappropriation of personal funds for one resident. The former Assistant Housekeeping Supervisor was identified as responsible for misappropriating over $8,200 from Resident #1’s debit card during his absence from the facility.

The survey conducted on 08/05/25 revealed the facility met all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

The SA is recommending that the facility be placed back in compliance effective 09/17/25. No deficiencies were cited in this desk review.

CI MS # 2592606: Anonymous complaint investigation regarding meal services, resident rights, Quality of Care, and activities of daily living; no deficiencies were cited.

The facility was found to have no deficiencies cited during this complaint investigation survey. However, the facility remains out of compliance due to deficiencies cited on the 08/07/25 survey.

The complaint investigation was substantiated. The agency nurse was found to have diverted medications and committed significant medication errors. Corrective actions were implemented by 6/25/25, and the facility was found in compliance as of 7/3/25.

The facility failed to ensure residents were free from misappropriation of medications and significant medication errors affecting multiple residents. Investigations revealed that LPN #2 signed out controlled substances without administering them, and multiple medications were documented as given but remained unopened on the medication cart.

Two Complaint Investigations were conducted: CI MS #477262 related to activities of daily living, pest control and staffing was found in compliance; CI MS #477259 related to narcotic diversion and significant medication errors was not in compliance with cited deficiencies F602 and F760. Corrective actions for these were implemented and found in compliance effective 7/3/25.

The facility was found not in compliance with several requirements including resident participation in care planning, freedom from misappropriation of medications, timely and accurate resident assessments, and medication administration. Corrective actions were implemented and the facility was found in compliance for some issues prior to the survey.

The facility was found to have a deficiency in maintaining a complete manual fire alarm system as required by NFPA 72 and NFPA 101. A trouble signal was observed on the fire alarm system panel and the facility was unable to provide sensitivity inspection records for the last two years.

The facility failed to ensure resident participation in care planning for two residents, failed to complete and transmit multiple MDS assessments timely for several residents, and failed to accurately code one resident's discharge MDS assessment. All deficiencies were cited with minimal harm and affected few residents.

Complaint CI MS #28752 involved environmental concerns related to foul odors and was investigated with no deficiencies cited.

The facility was found to be in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited during this complaint investigation.

The State Agency found the facility in compliance and is recommending that it be placed back in compliance effective 05/01/25.

The complaint investigation found that Residents #5 and #6 missed multiple scheduled showers in March 2025. Both residents were cognitively intact and reported missed showers. Staff interviews and review of Continuous Pressure Ulcer Monitoring sheets confirmed missing documentation and showers. The CNA Supervisor and RN Supervisor acknowledged the issue and the need for improved tracking and documentation systems.

The facility failed to implement comprehensive care plans and provide scheduled showers for two residents, Resident #5 and Resident #6, resulting in missed personal hygiene care. Documentation and staff interviews confirmed multiple missed showers in March 2025, indicating inadequate tracking and follow-through on care plans.

Five complaint investigations were conducted (CI MS# 27427, CI MS #27866, CI MS #27934, CI MS #28344, and CI MS #28380). Deficiencies were cited for CI MS #27427, CI MS #28380, and CI MS #27866 related to ADL needs. CI MS #27934 and CI MS #28344 had no deficiencies cited.

The facility failed to implement comprehensive care plans and provide adequate personal hygiene care for two of six residents reviewed, Resident #5 and Resident #6, who missed multiple scheduled showers in March 2025. Documentation and interviews confirmed these deficiencies, and staff acknowledged the need for improved tracking and care plan adherence.

Three complaint investigations were conducted: CI MS #26767 and CI MS #26778 related to neglect allegations, and CI MS #27190 related to transfer and discharge rights. No deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid participation requirements with no deficiencies cited during the complaint investigations.

The SA is recommending that the facility be placed back in compliance effective 09/11/24. No deficiencies were cited during this revisit.

The complaint investigation was initiated due to Resident #1 eloping from the facility unsupervised on 8/15/24. The Immediate Jeopardy was identified and notified to the facility on 8/19/24. The facility submitted a Removal Plan and completed corrective actions by 8/19/24, with the Immediate Jeopardy removed on 8/20/24. The State Agency validated the removal during the on-site investigation.

The facility failed to implement effective care plan interventions and provide adequate supervision for Resident #1, who eloped from the facility unsupervised. This failure placed the resident and others at risk of serious harm. Immediate Jeopardy was identified and later removed after corrective actions were completed.

CI MS# 26203 involved an elopement incident where Resident #1 left the facility unsupervised and was found at a grocery store 0.3 miles away. The complaint was substantiated with deficiencies cited and Immediate Jeopardy identified and removed.

The facility failed to provide adequate supervision and implement an effective care plan to prevent elopement for Resident #1, placing the resident and others at risk of serious harm. Immediate Jeopardy was identified and removed after corrective actions were completed.

Complaint number CI MS# 25034 was investigated to determine compliance with the 2012 Life Safety Code; the facility was found in compliance and no deficiencies were cited.

This survey found the facility to be in compliance with the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), and no deficiencies were cited.

The facility was found deficient in accurately coding resident assessments and in providing adequate care related to nail care for residents dependent on staff assistance. Specifically, one resident's Minimum Data Set (MDS) assessment was inaccurately coded, and another resident did not receive proper nail care as required by their care plan.

The survey included three complaints: MS CI #23620 related to Medication Storage was cited but corrected prior to the survey; MS CI #23674 related to Discharge Rights and oversedation had no deficiencies cited; MS CI #24333 related to Resident Rights, Dietary Services, Physical Environment, and Quality of Care had no deficiencies cited.

The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm due to failure to provide adequate nail care for a resident dependent on staff for Activities of Daily Living.

The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements.

The complaint investigation was substantiated. A resident took six tablets of Tramadol 50 mg after a medication card was left unsecured by staff. The resident was hospitalized for monitoring and returned without harm. Staff involved were suspended and terminated. The incident was reported to the State Department of Health, Attorney General's Office, and Police Department.

The facility failed to properly store narcotic medications delivered by the pharmacy, resulting in a resident taking medication not prescribed to her. The incident was investigated, staff involved were disciplined, and corrective actions including staff education and monitoring were implemented.

The State Agency is recommending that the facility be placed back in compliance effective 03/24/23. No deficiencies were cited in this desk review.

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.

The complaint investigation revealed failures related to regulatory requirements for change in status reporting, care planning, and pressure ulcer management. The findings were substantiated with interviews, record reviews, and policy evaluations.

The facility failed to submit a required Change in Status form for a resident diagnosed with anxiety disorder, did not develop a baseline care plan within 48 hours of admission for one resident, failed to develop a comprehensive person-centered care plan for the anxiety disorder diagnosis, and failed to provide timely assessment and treatment for pressure ulcers in another resident.

The facility was found not in compliance with Medicare and Medicaid regulations, citing deficiencies in coordination of PASARR and assessments, baseline care plan development, comprehensive care plan development, and treatment of pressure ulcers.

CI MS #18726: Allegations of Neglect, Quality of Care/Pressure sore prevention, Quality of Care/RP not notified of changes in condition and Admit/Transfer/Discharge Rights were not substantiated; no deficiencies cited.

The State Agency did not substantiate the complaint and found the facility in compliance with Medicare and Medicaid requirements. No deficiencies were cited.

The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by CMS and CDC regulations.

Complaint investigation CI MS #17879 related to a complaint survey conducted on 8/18/21. The facility met all plan of correction measures and no deficiencies were cited.

The surveyor determined the facility met all plan of correction measures stated in the 2567 and with the requirements for participation in Medicare and Medicaid.

Complaint #17879 was an anonymous complaint alleging mold in several rooms. The complaint was substantiated with deficiencies cited for mold presence and facility failure to maintain a safe and clean environment.

The facility was found not in compliance due to black biological growth (mold) observed in one of three shower rooms around a closed vent and on a wall near a sharps container. The facility lacked a policy for mold or mildew and had mold inside a wall in Resident room 130 that was recently removed and replaced.

The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, which has the potential to cause more than minimal harm to all residents.

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.

Complaint investigation CI MS #17750 related to abuse and/or neglect was not substantiated and no deficiencies were cited.

The facility was found to be in substantial compliance with the Minimum Standards for the Aged or Infirm requirements of participation. No deficiencies were cited and the complaint related to abuse and/or neglect was not substantiated.

Complaint investigations CI MS #17486 and CI MS #17566 were not substantiated for discharge, neglect, or quality of care/treatment.

The facility was found to be in compliance with the Centers for Medicare and Medicaid regulations. No deficiencies were cited.

CI MS #17216 - The complaint investigation was conducted from 12/8/2020 through 12/9/2020. The complaint was not substantiated and no deficiencies were cited.

The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and CMS and CDC recommended practices for COVID-19. The complaint investigation did not substantiate any deficiencies.

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

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

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

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

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

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

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

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

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.

CI MS #16433 was substantiated for behaviors and deficiencies were cited, specifically F657.

The facility failed to update the comprehensive care plan for resident behaviors for one of 21 resident care plans reviewed. Resident #89 exhibited multiple behavioral incidents that were not reflected in the care plan until the survey date.

Complaint investigation CI MS #16394 & CI MS #16400 was unsubstantiated with no deficiencies cited.

The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.

CI MS #16141 & CI MS #16185: Complaint investigation conducted and found unsubstantiated with no deficiencies cited.

The result of the investigation was unsubstantiated with no deficiencies cited.

The facility was found to have deficiencies related to residents' rights, comprehensive care plans, and medical records management. The facility also failed to ensure timely generator power transfer during testing.