Inspection Reports for
Starkville Manor Health Care and Rehabilitation Center
1001 Hospital Rd, Starkville, MS 39759, United States, MS, 39759
Back to Facility Profile56 Reports
Inspection Report — Aug 13, 2026
Annual Inspection
Date: Aug 13, 2026
Visit Reason
The State Agency conducted a desk review of information related to the annual recertification/complaint survey completed from 07/13/26 through 07/15/26. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 08/10/26. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 30, 2026
Complaint Investigation
Date: Jul 30, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #3104552, CI MS #3118659, and CI MS #3104171) at the facility from 07/29/26 through 07/30/26.
Complaint Details
Three complaint investigations (CI MS #3104552, CI MS #3118659, and CI MS #3104171) were conducted; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements, with no deficiencies cited during this survey.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Jul 15, 2026
Life Safety
Date: Jul 15, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Jul 15, 2026
Annual Inspection
Date: Jul 15, 2026
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations (CI) MS# 3053540 and CI MS# 3067819 at the facility from 07/13/26 through 07/15/26. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F800. CI MS# 3053540 and CI MS# 3067819 were investigated with no deficiencies cited.
Complaint Details
Complaint investigations CI MS# 3053540 and CI MS# 3067819 were investigated with no deficiencies cited.
Findings
The facility failed to provide an individualized therapeutic renal diet by not assessing and incorporating Resident #4's food preferences into the therapeutic diet. The resident received repetitive meals lacking meat and expressed dissatisfaction, leading to meals being ordered from outside. The dietary department had not yet interviewed residents for preferences, and the resident's preferences were not documented or met.
Deficiencies (1)
F0800 - Provided Diet Meets Needs of Each Resident. The facility failed to provide an individualized therapeutic renal diet by not assessing and incorporating Resident #4's food preferences, resulting in repetitive meals lacking meat and resident dissatisfaction.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 6, 2026
Annual Inspection
Date: Apr 6, 2026
Visit Reason
On 04/06/26 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 03/05/26. 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 SA is recommending that the facility be placed back in compliance effective 03/31/26. No deficiencies were cited in this document.
Inspection Report — Mar 5, 2026
Annual Inspection
Date: Mar 5, 2026
Visit Reason
The State Agency (SA) conducted an Annual Recertification survey along with three (3) Complaint Investigations (CI MS #2733582, CI MS #2794631, and CI MS #2795031) at the facility from 3/3/26 - 3/5/26. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Complaint Details
The survey included three complaint investigations: CI MS #2733582 with deficiency F0565 cited, CI MS #2794631 with deficiency F0689 cited, and CI MS #2795031 with no deficiencies cited.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited related to resident grievances about food preferences, discharge notification, accident prevention, and infection control.
Deficiencies (4)
F0565 - Resident and family grievances were not promptly addressed and resolved related to food preferences for 14 of 29 sampled residents who expressed concerns about lack of meat at breakfast and portion sizes.
F0628 - The facility failed to send a copy of the written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for one resident discharged home.
F0689 - The facility failed to provide adequate supervision and assistance to prevent an avoidable fall for one resident who rolled out of bed due to lack of clear communication about required staff assistance and removal of side rails.
F0880 - The facility failed to adhere to infection control measures when a dinner tray containing perishable food was left in a resident's room overnight.
Report Facts
Deficiencies cited: 4
Complaint investigations: 3
Inspection Report — Mar 4, 2026
Life Safety
Date: Mar 4, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Jan 28, 2026
Plan of Correction
Date: Jan 28, 2026
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2026-01-05 to verify corrective measures taken by the facility.
Complaint Details
The visit was related to a complaint survey completed on 2026-01-05; the facility's corrective measures were reviewed and found satisfactory.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 2026-01-27.
Report Facts
Survey completion date: Jan 28, 2026
Complaint survey date: Jan 5, 2026
Inspection Report — Jan 5, 2026
Complaint Investigation
Date: Jan 5, 2026
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 01/05/2026 regarding resident rights.
Complaint Details
Complaint Investigation MS #2671620 for resident rights. The complaint was substantiated as the facility failed to ensure dignity and respect for Resident #1.
Findings
The facility failed to ensure a resident's right to be treated with dignity and respect for one of five residents sampled. Interviews with the resident, staff, and administrator confirmed that a Certified Nursing Assistant treated the resident in a hurried and rude manner, violating resident rights.
Deficiencies (1)
Failed to ensure a resident's right to be treated with dignity and respect.
Report Facts
Residents sampled: 5
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in dignity and respect deficiency for unprofessional conduct and failure to treat resident with dignity and respect |
| Administrator | Administrator | Interviewed regarding the complaint and corrective actions taken |
Inspection Report — Jan 5, 2026
Plan of Correction
Date: Jan 5, 2026
Visit Reason
The document is a statement of deficiencies and plan of correction related to a nursing home survey conducted to evaluate compliance with resident rights and care standards.
Findings
The facility failed to ensure a resident's right to be treated with dignity and respect for one of five residents sampled. A Certified Nursing Assistant was found to have acted unprofessionally and was subsequently removed from the resident's care.
Deficiencies (1)
Failure to ensure a resident's right to be treated with dignity and respect by a Certified Nursing Assistant.
Report Facts
Residents sampled: 5
Residents affected: 1
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Named in the deficiency for unprofessional conduct and failure to treat resident with dignity and respect | |
| Administrator | Interviewed regarding the deficiency and corrective actions |
Inspection Report — Nov 14, 2025
Plan of Correction
Date: Nov 14, 2025
Visit Reason
The State Agency conducted a desk review of information provided related to the annual survey completed on 2025-09-10 to verify corrective measures taken by the facility.
Findings
The facility demonstrated that it had implemented measures to correct the previously identified deficient practices and sustain compliance with Medicare and Medicaid participation requirements. The State Agency recommended the facility be placed back in compliance effective 2025-10-08.
Report Facts
Survey completion date: Nov 14, 2025
Annual survey date: Sep 10, 2025
Compliance effective date: Oct 8, 2025
Inspection Report — Sep 10, 2025
Annual Inspection
Date: Sep 10, 2025
Visit Reason
The State Agency conducted an annual re-certification survey with two complaint investigations at the facility from 09/08/2025 through 09/10/2025. The complaint investigations involved a resident-to-resident sexual abuse incident and quality of care concerns.
Complaint Details
Two complaint investigations were conducted: CI MS #482439 related to a resident-to-resident sexual abuse incident and CI MS #482443 related to quality of care. Deficiencies were cited related to the sexual abuse complaint, but no deficiencies were cited related to the quality of care complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for multiple deficiencies including failure to ensure resident dignity during meals, failure to implement comprehensive care plans, failure to provide assistance with activities of daily living, failure to apply physician-ordered splinting devices, and failure to submit accurate staffing data to CMS. Corrective actions and quality monitoring plans were initiated.
Deficiencies (5)
Failure to ensure the dignity of a resident needing supervision and/or assistance with meals during dining (Resident #4).
Failure to develop and implement a comprehensive care plan for the application of a splinting device (Resident #4) and failure to implement a resident's ADL care plan related to personal hygiene and grooming (Resident #29).
Failure to provide assistance with meals (Resident #4) and failure to provide personal hygiene and grooming for a dependent resident (Resident #29).
Failure to ensure a resident with a contracture received necessary treatment and services to prevent decline in range of motion, evidenced by failure to apply a physician-ordered hand splint (Resident #4).
Failure to submit complete and accurate staffing data to CMS through Payroll-Based Journal reporting during Quarter 3 of Fiscal Year 2025.
Report Facts
Deficiencies cited: 5
PBJ staffing hours discrepancy: 15.07
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Director of Nursing | Named in medication error finding |
Inspection Report — Sep 10, 2025
Annual Inspection
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, including dignity, care planning, assistance with activities of daily living, range of motion maintenance, and staffing data accuracy.
Findings
The facility was found deficient in multiple areas including failure to ensure dignity and assistance during meals for a resident with physical impairments, failure to implement care plans for splint application and personal hygiene, failure to provide assistance with activities of daily living, failure to maintain range of motion due to not applying a physician-ordered hand splint, and failure to submit accurate staffing data to CMS.
Deficiencies (5)
Failed to ensure the dignity of a resident needing supervision and assistance with meals, resulting in food spilling and lack of staff assistance during dining.
Failed to implement a care plan for the application of a splinting device and failed to implement a resident's ADL care plan related to personal hygiene and grooming.
Failed to provide assistance with meals and personal hygiene for dependent residents.
Failed to apply a physician-ordered hand splint to prevent contracture, resulting in potential worsening of range of motion impairment.
Failed to submit complete and accurate direct care staffing data to CMS through Payroll-Based Journal reporting for Quarter 3 of FY 2025.
Report Facts
Residents reviewed for dignity during meals: 5
Residents reviewed for care plans: 21
Residents residing in facility: 106
PBJ staffing hours discrepancy on 6/8/25: 15.02
PBJ staffing hours discrepancy on 6/15/25: 15.75
PBJ staffing hours discrepancy on 6/22/25: 6.88
PBJ staffing hours discrepancy on 6/28/25: 7.97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Confirmed staff responsibility for supervising residents during mealtimes and acknowledged need to assist Resident #4. |
| Rehab Director | Confirmed Resident #4 should be assisted during meals and that failure to apply hand splint could worsen contracture. | |
| Certified Occupational Therapy Assistant (COTA) | Expressed concern about dignity related to Resident #4 having to eat with his hands. | |
| Administrator | Stated expectation for staff to provide supervision and assistance at mealtimes and confirmed expectation for splinting devices to be applied according to physician orders. | |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Confirmed failure to apply Resident #4's hand splint and acknowledged miscommunication about responsibility. |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Confirmed Resident #29's hair was matted and had not been washed in about two weeks. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Confirmed Resident #29's hair was matted with crusty substance and care plan was not followed. |
Inspection Report — Sep 17, 2024
Complaint Investigation
Date: Sep 17, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI) MS 26498 at the facility on 9/17/24 related to allegations of abuse and misappropriation.
Complaint Details
Complaint investigation MS 26498 was conducted and found no deficiencies related to abuse and misappropriation; the complaint was not substantiated.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm, with no deficiencies cited related to abuse and misappropriation.
Report Facts
Inspection Report — Aug 14, 2024
Re-Inspection
Date: Aug 14, 2024
Visit Reason
The State Agency conducted an onsite revisit related to the annual survey completed on 07/02/24 to verify correction of previously identified deficiencies.
Findings
The facility had implemented measures to correct the deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 08/05/24.
Inspection Report — Aug 14, 2024
Follow-Up
Date: Aug 14, 2024
Visit Reason
The State Agency conducted an onsite revisit related to the annual survey completed on 07/02/24 to verify correction of previously identified deficiencies.
Findings
The facility had implemented measures to correct the deficient practices and sustain compliance with State Requirements and Regulations for the Aged and Infirm. The State Agency recommended the facility be placed back in compliance effective 08/05/24.
Inspection Report — Aug 13, 2024
Complaint Investigation
Date: Aug 13, 2024
Visit Reason
The State Agency conducted an onsite complaint investigation for alleged neglect and verbal abuse of a resident.
Complaint Details
Complaint investigation CI MS#26006 for alleged neglect and verbal abuse of a resident; no deficiencies were cited and the facility was found in compliance.
Findings
The facility was found to be in compliance with the Standards for Participation in Medicare and Medicaid with no deficiencies cited during this investigation. However, the facility remains out of compliance due to deficiencies cited in a prior survey dated 07/02/24.
Report Facts
Licensed beds: 119
Inspection Report — Jul 2, 2024
Complaint Investigation
Date: Jul 2, 2024
Visit Reason
The State Agency conducted complaint investigations at the facility from 7/1/24 through 7/2/24 related to resident rights and abuse allegations.
Complaint Details
Complaint investigations MS #25350, MS #25510, and MS #25714 were conducted. Noncompliance was found for MS #25510 related to resident rights and personal funds. The facility was compliant for MS #25350 and MS #25714 related to abuse with no deficiencies cited.
Findings
The facility was found not in compliance with Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm for resident rights related to personal funds for two residents. The facility failed to ensure residents' personal funds were available for use on the same day as requested. The facility was in compliance for abuse-related complaints.
Deficiencies (1)
Facility failed to ensure residents' personal funds were available for use on the same day as requested for two of five residents reviewed for personal funds.
Report Facts
Trust Fund Petty Cash: 750
Trust Fund Petty Cash: 1200
Residents reviewed for personal funds: 5
Residents with fund availability issues: 2
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding resident trust fund petty cash and fund disbursement procedures | |
| Receptionist | Interviewed regarding resident money requests and fund availability | |
| Social Worker | Interviewed as witness verifying amounts of money obtained by residents | |
| Administrator | Acknowledged facility's failure to keep adequate resident funds available and confirmed regulatory requirements | |
| Executive Director | Conducted staff education and ongoing quality monitoring related to resident trust fund availability |
Inspection Report — Jul 2, 2024
Date: Jul 2, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding residents' rights to manage their personal financial affairs, specifically focusing on the availability of residents' personal funds upon request.
Findings
The facility failed to ensure that residents' personal funds were available on the same day as requested for two of five residents reviewed. Interviews with residents and staff revealed that the facility often did not have enough cash on hand to meet residents' requests, causing delays. The Administrator acknowledged these delays and confirmed the facility's failure to maintain adequate funds as required by regulations.
Deficiencies (1)
Failed to ensure a resident's personal funds were available for use on the same day as requested for two residents.
Report Facts
Amount kept in locked box: 750
Resident cash request threshold: 50
Resident cash request threshold: 100
Resident cash request threshold: 70
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding cash disbursement procedures and availability. | |
| Receptionist | Interviewed about residents requesting money and cash availability. | |
| Social Worker | Interviewed as a witness verifying amounts of money obtained by residents. | |
| Administrator | Acknowledged facility's failure to maintain adequate funds for residents. |
Inspection Report — Mar 19, 2024
Re-Inspection
Date: Mar 19, 2024
Visit Reason
The State Agency conducted a revisit survey at the facility from 03/18/24 through 03/19/24 to verify compliance with previously cited deficiencies related to resident rights, activities of daily living, and pressure ulcers.
Findings
The facility was placed back into compliance as of 03/08/24 for deficiencies related to resident rights (M500), activities of daily living (M610), and pressure ulcers (M615).
Inspection Report — Feb 6, 2024
Annual Inspection
Date: Feb 6, 2024
Visit Reason
The State Agency conducted an annual recertification survey from 1/29/24 through 2/06/24 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with resident rights, pressure sore care, and activities of daily living. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified related to failure to timely treat wounds and follow physician orders, resulting in worsening pressure ulcers and risk of serious harm. The facility failed to provide adequate wound care, delayed x-rays and antibiotic treatment, and failed to provide proper activities of daily living care including shaving and nail care for dependent residents.
Deficiencies (2)
Failure to implement physician orders for wound care and treatments for residents with pressure ulcers, resulting in worsening wounds and delayed treatment.
Failure to provide activities of daily living care including shaving and nail care for dependent residents.
Report Facts
Body audits completed: 108
Residents refusing body audit: 7
Braden Score: 14
Wound measurements: 5
Wound measurements: 5.4
Wound measurements: 2.2
Wound measurements: 2.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Nurse | Named in failure to implement physician orders for wound care and treatments. | |
| Wound Nurse Practitioner | Named in failure to timely order and follow up on x-ray for osteomyelitis. | |
| Assistant Director of Nursing | Named in education and monitoring of wound care and activities of daily living. | |
| Director of Nursing | Named in education and monitoring of wound care and activities of daily living. | |
| Licensed Practical Nurse #4 | Named in wound care treatment and documentation issues. | |
| Licensed Practical Nurse #5 | Named as primary nurse unaware of wound care orders. | |
| Registered Nurse #3 | Named as unit manager unaware of wound care orders. | |
| Certified Nursing Assistants | Named in failure to provide shaving and nail care. |
Inspection Report — Feb 6, 2024
Annual Inspection
Date: Feb 6, 2024
Visit Reason
The State Agency conducted an annual recertification survey to determine compliance with Medicare and Medicaid participation requirements, including investigation of an Immediate Jeopardy related to wound care and professional standards.
Findings
The facility was found not in compliance with multiple regulatory requirements including failure to implement physician orders for wound care, delayed treatment of pressure ulcers, inadequate pain management, and failure to monitor and document care properly. An Immediate Jeopardy was identified and later removed after corrective actions including termination of the wound nurse and staff education.
Deficiencies (10)
Failure to implement physician orders for wound care and treatments for residents with pressure ulcers, resulting in worsening wounds and risk of serious harm.
Failure to develop and implement comprehensive care plans for residents with wounds and related care needs such as nail care and shaving.
Failure to revise resident care plan to reflect current pain management orders, resulting in inadequate pain control.
Failure to meet professional standards of quality in documenting and providing medical treatments for wounds, including delayed antibiotic treatment and incomplete wound care documentation.
Failure to provide sufficient nursing staff with appropriate competencies and skills to provide wound care and related services, resulting in delayed and inadequate treatment.
Failure to provide effective pain management for a resident with wounds, including failure to assess pain adequately and adjust treatment accordingly.
Failure to provide Activities of Daily Living (ADL) care including shaving and nail care for dependent residents.
Failure to monitor signs and symptoms of hypo/hyperglycemia for residents receiving insulin.
Failure to properly label and store drugs and biologicals, including leaving medications unattended at resident bedside.
Failure to submit accurate staffing data into the Payroll-Based Journal (PBJ) system, including failure to capture weekend staffing hours correctly.
Report Facts
Deficiencies cited: 12
Body audits conducted: 108
Residents refusing audit: 7
Wound measurements: 5
Wound measurements: 5.4
Wound measurements: 2.2
Pain BIMS score: 7
BIMS score: 7
BIMS score: 11
BIMS score: 9
BIMS score: 13
BIMS score: 8
BIMS score: 15
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Medication doses missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Left medication unattended at bedside for Resident #106 |
| LPN #4 | Licensed Practical Nurse | Reported wound care order discontinued and medication administration issues for Resident #52 |
| LPN #2 | Licensed Practical Nurse | Responsible for wound care for Resident #52 and Resident #103, admitted delay in treatment and documentation |
| RN #3 | Unit Manager | Unaware of x-ray order for Resident #269 |
| Assistant Director of Nursing | Oversaw wound care issues, education, and monitoring; confirmed lack of wound nurse training | |
| Director of Nursing | Oversaw wound care issues, education, and monitoring; confirmed wound nurse training was insufficient | |
| Wound Nurse Practitioner | Delayed x-ray order and antibiotic treatment for Resident #269 | |
| Wound Nurse | Failed to follow wound care orders and documentation, delayed treatment, and failed to report issues | |
| Resident #103 | Resident | Reported pain during wound care not adequately managed |
| Administrator | Notified of Immediate Jeopardy and oversaw corrective actions | |
| Human Resources Director | Responsible for Payroll-Based Journal staffing data submission |
Inspection Report — Feb 6, 2024
Complaint Investigation
Date: Feb 6, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to implement physician orders for wound care and treatments, neglect, and failure to provide appropriate care and services to residents with wounds and pressure ulcers.
Complaint Details
The complaint investigation revealed failure to implement physician orders for wound care, neglect, failure to provide appropriate care and services, and inadequate staff training and documentation, resulting in immediate jeopardy to resident health and safety.
Findings
The facility failed to protect residents from neglect by not following physician orders for wound care for multiple residents, resulting in worsening wounds and risk of serious harm. There were delays in obtaining diagnostic tests and treatments, failure to provide appropriate wound care, and inadequate staff training and documentation. Immediate Jeopardy was identified and later removed after corrective actions including staff termination, education, and monitoring were implemented.
Deficiencies (8)
Failure to implement physician orders for wound care and treatments for multiple residents, resulting in worsening wounds and risk of serious harm.
Failure to develop and implement a complete care plan that meets all the resident's needs, including wound care and grooming.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to provide safe, appropriate pain management for a resident with wounds.
Failure to ensure nurses and nurse aides have the appropriate competencies to care for residents with skin concerns and pressure ulcers.
Failure to ensure drugs and biologicals are stored properly and securely.
Failure to submit accurate staffing data into the Payroll-Based Journal (PBJ) system.
Failure to provide monitoring for signs and symptoms of hypo/hyperglycemia for residents receiving insulin.
Report Facts
Deficiencies cited: 5
Residents affected: 3
Body audits conducted: 108
Residents refused body audit: 7
Braden Score: 14
Wound measurements: 5.2
Wound measurements: 6.2
Wound measurements: 0.2
Wound measurements: 18.72
Wound measurements: 3.744
Wound measurements: 3.5
Wound measurements: 2.5
Wound measurements: 3.5
Wound measurements: 6.2
Wound measurements: 2.3
Wound measurements: 8.2
Wound measurements: 18.86
Wound measurements: 3.772
Wound measurements: 0.8
Wound measurements: 1.5
Wound measurements: 0.1
Wound measurements: 1.2
Wound measurements: 1
Wound measurements: 1.2
Wound measurements: 0
Wound measurements: 1.2
Pain rating: 7
Staff training attendance: 5
Staff training attendance: 6
Staff training attendance: 4
Staff training attendance: 8
Staff training attendance: 6
Staff training attendance: 5
Staff training attendance: 5
Body audits conducted: 108
Residents refused body audit: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in wound care treatment and documentation deficiencies, weekend wound care issues |
| Wound Nurse | Named in multiple wound care treatment, documentation, and communication deficiencies | |
| Wound Nurse Practitioner | Named in wound care treatment delays and communication failures | |
| Director of Nursing | DON | Named in oversight and communication failures related to wound care |
| Assistant Director of Nursing | ADON | Named in oversight and communication failures related to wound care |
| Administrator | Administrator | Named in notification and oversight of Immediate Jeopardy and corrective actions |
| Human Resources Director | HR Director | Named in Payroll-Based Journal staffing data submission errors |
Inspection Report — Jan 31, 2024
Life Safety
Date: Jan 31, 2024
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 Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report — Jan 31, 2024
Date: Jan 31, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements during the survey.
Inspection Report — Dec 19, 2023
Complaint Investigation
Date: Dec 19, 2023
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2023-11-08 to determine compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
The visit was a desk review following a complaint survey. The facility was found to be in compliance and the complaint was effectively resolved.
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 2023-12-08.
Inspection Report — Dec 5, 2023
Complaint Investigation
Date: Dec 5, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for CI MS #23480 on 12/05/23.
Complaint Details
Complaint Investigation CI MS #23480 was conducted and found no deficiencies; the complaint was not substantiated.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited. However, the facility remains out of compliance for deficiencies cited in the prior 11/08/2023 survey.
Report Facts
Inspection Report — Nov 8, 2023
Complaint Investigation
Date: Nov 8, 2023
Visit Reason
The State Agency conducted a complaint investigation from 11/07/23 through 11/08/23 due to allegations of misappropriation of resident trust funds.
Complaint Details
Complaint investigation MS#23177 was substantiated with findings of misappropriation of resident trust funds involving three residents. The incident was reported to the Attorney General, State Department of Health, and Starkville Police Department. A 100% audit of all residents with trust fund accounts identified 31 residents affected, all of whom were refunded.
Findings
The facility failed to employ proper bookkeeping techniques for individual resident trust funds, resulting in misappropriation of funds for three residents. An audit revealed multiple unauthorized withdrawals and missing receipts, leading to reimbursement of affected residents. The former Business Office Manager was terminated for poor work performance and misappropriation. The facility implemented corrective actions including audits, staff education, and ongoing monitoring.
Deficiencies (2)
Failed to employ proper bookkeeping techniques for individual resident trust funds for three residents.
Failed to protect residents' rights to be free from misappropriation of property from Resident Trust Funds for three residents.
Report Facts
Residents with trust funds: 111
Residents affected by misappropriation: 29
Residents refunded: 31
Total amount reimbursed: 4439.67
Variance amounts for Resident #1: 1641.71
Variance amounts for Resident #2: 50
Variance amounts for Resident #3: 114.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Terminated for poor work performance and misappropriation of resident funds | |
| Administrator | Conducted interviews and oversaw audit and corrective actions | |
| Regional Director of Business Office Services | Conducted audit and investigation of resident trust fund accounts | |
| Social Services Director | Interviewed residents and identified suspicious transactions | |
| Executive Director | Reported incident to authorities and initiated staff training and quality assurance monitoring |
Inspection Report — Nov 8, 2023
Complaint Investigation
Date: Nov 8, 2023
Visit Reason
The visit was conducted as a complaint survey triggered by a complaint received by the State Agency.
Complaint Details
The complaint survey was completed on 11/08/23. The facility provided information confirming corrective measures were taken. The State Agency recommended the facility be placed back in compliance effective 12/08/23.
Findings
The State Agency conducted a desk review of information related to the complaint survey and confirmed that the facility had implemented measures to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 12/08/23.
Inspection Report — Nov 8, 2023
Complaint Investigation
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to concerns regarding misappropriation of resident funds by the former Business Office Manager, triggered by suspicious transactions found during an audit initiated after her termination.
Complaint Details
The investigation was initiated after the termination of the Business Office Manager for poor work performance and attendance, during which an audit revealed misappropriation of resident funds. Resident #1 denied requesting large withdrawals, and multiple residents were found to have missing funds that were later reimbursed. The issue was discovered through staff interviews, record reviews, and resident interviews.
Findings
The facility failed to properly hold, secure, and manage residents' personal money deposited with the nursing home, resulting in misappropriation of funds for three residents. The audit revealed missing withdrawal tickets, unauthorized withdrawals, and unaccounted funds totaling $4,439.67, affecting 29 residents out of 111 with trust funds.
Deficiencies (2)
Failed to employ proper bookkeeping techniques for individual resident funds, resulting in misappropriation of funds for three residents.
Failed to protect residents from wrongful use of their belongings or money, including theft and unauthorized withdrawals.
Report Facts
Residents with Trust Funds: 111
Residents affected: 29
Total reimbursed amount: 4439.67
Variance amounts: 15.34
Variance amounts: 20
Variance amounts: 300
Variance amounts: 206.41
Variance amounts: 500
Variance amounts: 600
Variance amounts: 20
Variance amounts: 30
Variance amounts: 69
Variance amounts: 45.8
Withdrawal requests: 1600
Withdrawal requests: 600
Withdrawal requests: 700
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Former Business Office Manager | Terminated on 10/20/2023 for poor work performance and attendance; responsible for misappropriation of resident funds |
| Administrator | Administrator (ADM) | Interviewed regarding audit findings and corrective actions |
| Regional Director of Business Office Services | Regional Director of Business Office Services (RDBOS) | Interviewed regarding discovery of suspicious transactions and audit |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding resident interviews and discovery of suspicious checks |
Inspection Report — Aug 3, 2023
Complaint Investigation
Date: Aug 3, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility from 8/2/23 through 8/3/23 related to documentation of pressure ulcer care.
Complaint Details
Complaint survey MS #21960 was conducted and the facility was found compliant.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements related to documentation of pressure ulcer care.
Report Facts
Inspection Report — Jun 22, 2023
Complaint Investigation
Date: Jun 22, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility from 6/21/23 through 6/22/23 to investigate a complaint regarding Residents Rights.
Complaint Details
Complaint survey MS #21623 was conducted; the complaint regarding Residents Rights was not substantiated.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaint was not substantiated and no deficiencies were cited.
Report Facts
Inspection Report — Apr 26, 2023
Re-Inspection
Date: Apr 26, 2023
Visit Reason
The State Agency conducted a revisit at the facility to verify compliance with previous deficiencies related to Administration and nursing services.
Findings
The facility was found to be back in compliance with the cited deficiencies as of 04/20/2023.
Report Facts
Licensed beds: 119
Inspection Report — Apr 25, 2023
Complaint Investigation
Date: Apr 25, 2023
Visit Reason
The State Agency conducted an onsite complaint investigation (CI MS #21332) due to allegations that the 2nd and 3rd shifts did not have enough staff and that resident supplies were not available.
Complaint Details
Complaint investigation CI MS #21332 alleged insufficient staffing on 2nd and 3rd shifts and lack of resident supplies; the complaint was not substantiated as no deficiencies were cited.
Findings
The State Agency determined that the facility was in substantial compliance with the Standards for Participation in Medicaid and Medicare Services and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the 3/14/2023 survey.
Report Facts
Licensed beds: 119
Inspection Report — Apr 5, 2023
Complaint Investigation
Date: Apr 5, 2023
Visit Reason
The State Agency conducted five complaint investigations at the facility from 04/04/2023 through 04/05/2023.
Complaint Details
Five complaint investigations (CI MS# 21043, CI MS# 021101, CI MS# 21109, CI MS# 21110, and CI MS# 21166) were conducted, and no deficiencies were found.
Findings
The facility was found to be in compliance with Medicare and Medicaid Services requirements with no deficiencies cited.
Report Facts
Number of complaint investigations: 5
Inspection Report — Mar 14, 2023
Complaint Investigation
Date: Mar 14, 2023
Visit Reason
The State Agency conducted three onsite complaint investigations for alleged environmental disrepairs, disrepair of the facility van lift, unavailable necessary patient equipment, shortages of nursing staff on second and third shifts, and a resident fall from a wheelchair on the facility van.
Complaint Details
The complaint investigations included allegations of environmental disrepairs, disrepair of the facility van lift, unavailable necessary patient equipment, shortages of nursing staff on second and third shifts, and a resident fall from a wheelchair on the facility van. The facility was confirmed to have staffing shortages on weekends for second and third shifts. The facility was found in compliance for the resident fall incident complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited for Resident Rights due to no survey results posted, insufficient nursing staff, unavailable and non-current nurse staffing information, and ineffective use of staffing resources. The facility had been short of nursing staff on weekends for second and third shifts for an extended period.
Deficiencies (4)
No survey results posted and accessible for residents, families, and visitors for three days of survey.
Insufficient nursing staff for the resident census of 103-108 for six days reviewed.
Unavailable, non-current, non-posted nurse staffing information.
Not utilizing staffing resources effectively and efficiently.
Report Facts
Total licensed beds: 119
Days with insufficient nursing staff: 6
Days with staffing shortages: 6
Number of CNAs on second shift: 6
Number of CNAs documented on staffing form: 8
Resident assignments per CNA: 12
Resident assignments per CNA (prior to contract staff): 30
BIMS score: 11
BIMS score: 9
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN#1 | Registered Nurse | Named in staffing insufficiency findings; lacked knowledge of census and staffing postings |
| CNA#1 | Certified Nursing Assistant | Named in staffing insufficiency findings; reported long-term staffing shortages |
| CNA#2 | Certified Nursing Assistant | Named in staffing insufficiency findings; confirmed staffing shortages on weekends |
| LPN#1 | Licensed Practical Nurse | Named in staffing insufficiency findings; lacked knowledge of census and staffing postings |
| LPN#2 | Licensed Practical Nurse | Named in staffing insufficiency findings; reported working alone on many weekend shifts |
| RN#2 | Registered Nurse | Named in staffing insufficiency findings; confirmed overtime use due to low staffing |
| ADM | Administrator | Named in staffing insufficiency findings; responsible for staffing schedules and call-ins |
| DON | Director of Nursing | Named in staffing insufficiency findings; worked many 16-hour shifts due to low staffing |
| NC | Nurse Consultant | Named in staffing insufficiency findings; reported delays in staffing grid production |
| AD | Activities Director / Certified Nursing Assistant | Named in staffing insufficiency findings; confirmed staffing shortages and working extra shifts |
Inspection Report — Mar 12, 2023
Complaint Investigation
Date: Mar 12, 2023
Visit Reason
The State Agency conducted three onsite complaint investigations from 03/12/23 through 03/14/23 related to environmental disrepairs, van lift disrepair, unavailable patient equipment, resident fall from a wheelchair on the facility van, and nursing staff shortages on second and third shifts most weekends.
Complaint Details
The complaint investigations included allegations of environmental disrepairs, van lift disrepair, unavailable necessary patient equipment, resident fall from wheelchair on facility van, and nursing staff shortages on second and third shifts most weekends. The facility was found non-compliant related to staffing shortages but compliant regarding the resident fall incident.
Findings
The facility was found not in compliance with state licensure requirements related to staffing shortages on second and third shifts most weekends. Deficiencies were cited for insufficient nursing staff and failure to maintain required staffing ratios. Interviews and record reviews confirmed chronic understaffing, lack of posted census and staffing information, and recent efforts to hire contract/agency staff to improve staffing levels.
Deficiencies (2)
Facility Administrator failed to ensure adequate staffing for all three shifts on weekends and after hours for six days reviewed.
Facility failed to provide sufficient qualified nursing staff for resident census of 103-108 for six days reviewed.
Report Facts
Total licensed beds: 119
Staffing ratio: 2.8
Days reviewed with staffing issues: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse RN#1 | Registered Nurse | Interviewed regarding staffing and census knowledge |
| Certified Nursing Assistant CNA#1 | Certified Nursing Assistant | Interviewed regarding staffing shortages and resident assignments |
| Certified Nursing Assistant CNA#2 | Certified Nursing Assistant | Interviewed regarding staffing shortages and resident assignments |
| Licensed Practical Nurse LPN#1 | Licensed Practical Nurse | Interviewed regarding staffing and census knowledge |
| Licensed Practical Nurse LPN#2 | Licensed Practical Nurse | Interviewed regarding staffing shortages and census knowledge |
| Registered Nurse RN#2 | Registered Nurse | Interviewed regarding staffing shortages and overtime |
| Administrator ADM | Facility Administrator | Interviewed regarding staffing efforts and scheduling |
| Director of Nursing DON | Director of Nursing | Interviewed regarding staffing shortages, overtime, and contract staff hiring |
| Nurse Consultant NC | Corporate Nurse Consultant | Interviewed regarding staffing grid and scheduling issues |
| Activities Director AD | Activities Director / Certified Nursing Assistant | Interviewed regarding staffing shortages and working extra shifts |
Inspection Report — Mar 12, 2023
Complaint Investigation
Date: Mar 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to post survey results, insufficient nursing staff to meet resident needs, and failure to post accurate nurse staffing information.
Complaint Details
The visit was complaint-related due to allegations of failure to post survey results, inadequate nursing staff coverage, and failure to post accurate staffing and census information. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to post survey results for three days, did not maintain sufficient nursing staff for resident care over multiple days, and failed to post accurate census and staffing information for three days. Staffing shortages were confirmed by multiple staff and residents, with recent improvements noted after hiring contract staff.
Deficiencies (4)
Failure to post survey results and assure accessibility to residents, families, and visitors for three days.
Failure to provide sufficient qualified nursing staff for the resident census of 103-108 for six days.
Failure to post the census and correct number of staff present on each shift for three days.
Failure to administer the facility in a manner that enables effective and efficient use of resources, specifically inadequate staffing for all shifts on weekends and after hours for six days.
Report Facts
Days of insufficient staffing: 6
Days survey results not posted: 3
Staffing counts: 5
Residents assigned per CNA: 12
MDS BIMS scores: 11
MDS BIMS scores: 9
MDS BIMS scores: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN#1 | Registered Nurse | Interviewed regarding staffing, census knowledge, and survey results posting |
| CNA#1 | Certified Nursing Assistant | Interviewed about staffing shortages and resident assignments |
| CNA#2 | Certified Nursing Assistant | Interviewed about staffing shortages and resident assignments |
| LPN#1 | Licensed Practical Nurse | Interviewed about staffing, census knowledge, and shift assignments |
| LPN#2 | Licensed Practical Nurse | Interviewed about staffing shortages and census knowledge |
| RN#2 | Registered Nurse | Interviewed about staffing shortages and overtime |
| ADM | Administrator | Interviewed about staffing, survey results posting, and scheduling |
| DON | Director of Nursing | Interviewed about staffing, survey results posting, and scheduling |
| NC | Nurse Consultant | Interviewed about staffing grid and scheduling issues |
| AD | Activities Director / Certified Nursing Assistant | Interviewed about staffing shortages and working extra shifts |
Inspection Report — Nov 30, 2022
Annual Inspection
Date: Nov 30, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey conducted on 10/19/22 to verify correction of previously identified deficient practices.
Findings
The facility provided information confirming that measures were put in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 11/18/22.
Inspection Report — Nov 22, 2022
Follow-Up
Date: Nov 22, 2022
Visit Reason
The State Agency conducted a follow-up survey to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid and was put back in compliance effective 11/18/2022.
Inspection Report — Oct 19, 2022
Annual Inspection
Date: Oct 19, 2022
Visit Reason
The State Agency conducted an annual recertification along with complaint investigations and a facility reported incident from 10/16/22 through 10/19/22 to determine compliance with Medicare and Medicaid participation requirements.
Complaint Details
Complaint investigations substantiated for Quality of Care related to resident being left soiled, not groomed, environment, and facility staffing. Complaint for verbal abuse was not substantiated.
Findings
The facility was found not in compliance with multiple regulatory requirements including quality of care, environment cleanliness, care plan implementation, ADL care, incontinent care, staffing sufficiency, medication security, food safety, and administration. Deficiencies were substantiated related to resident care, staffing shortages, medication cart security, food storage and preparation, and failure to hold quarterly QA meetings.
Deficiencies (9)
Failed to maintain a clean, comfortable environment with broken blinds, dirty bed rails, walls, call light cords, trash receptacles, and feeding pumps in multiple hallways.
Failed to implement comprehensive care plans related to Activities of Daily Living and incontinent care for residents.
Failed to provide Activities of Daily Living care and incontinent care for dependent residents.
Failed to provide incontinent care timely to heal skin breakdown for reoccurring Stage II pressure ulcers for one resident.
Failed to ensure sufficient nursing staff to provide adequate care and assistance for residents for 23 of 28 days reviewed.
Failed to ensure medication cart was locked and medications secured; medication cart found unlocked with medications unattended.
Failed to store, prepare, and serve foods in a sanitary manner; dirty oven, unlabeled food items, and crumbling ceiling tiles over prep table observed.
Failed to administer the facility in a manner that uses resources effectively and efficiently to meet resident needs; staffing shortages noted and not adequately addressed.
Failed to hold quarterly Quality Assurance meetings for two of four quarters reviewed.
Report Facts
Deficiency citations: 9
Staffing short days: 23
Staffing ratio lows: 1.83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Charge nurse on 10/16/22 3 PM-11 PM shift; reported staffing shortages. |
| DON | Director of Nursing | Confirmed staffing shortages and failure to follow care plans; responsible for staffing oversight. |
| Administrator | Acknowledged staffing challenges and failure to hold QA meetings. | |
| CNA #1 | Certified Nursing Assistant | Observed delayed incontinent care for Resident #105. |
| RN #2 | Registered Nurse | Wound care nurse for Resident #105; confirmed wounds worsened by delayed incontinent care. |
| DM #1 | Dietary Manager | Confirmed food safety violations including unlabeled food and dirty oven. |
| LPN #6 | Licensed Practical Nurse | Admitted leaving medication cart unlocked with medications unattended. |
Inspection Report — Oct 19, 2022
Life Safety
Date: Oct 19, 2022
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), specifically regarding corridor doors and their ability to resist smoke passage and properly latch.
Findings
The facility failed to properly protect corridor openings as required by NFPA 19 3.6.3.5, affecting two of five smoke compartments and 31 of 108 residents. Corridor doors to Rooms A-31, A-19, B-24, and B-18 were unable to close to a positive latching position and could not resist smoke passage.
Deficiencies (1)
Corridor doors to Rooms A-31, A-19, B-24, and B-18 were unable to close to a positive latching position and were incapable of resisting the passage of smoke.
Report Facts
Residents affected: 31
Smoke compartments affected: 2
Total residents present: 108
Total smoke compartments: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged the finding during the exit interview | |
| Maintenance Supervisor | Verified the observation during the exit interview and repaired the doors | |
| Executive Director | In-serviced Maintenance Director on NFPA 101 Corridor - Doors requirements | |
| Maintenance Director | Assigned to perform weekly inspections of corridor doors |
Inspection Report — Oct 19, 2022
Date: Oct 19, 2022
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 — Oct 19, 2022
Routine
Date: Oct 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, staffing, medication management, and quality assurance.
Findings
The facility was found deficient in maintaining a clean and safe environment, providing adequate care plans and ADL assistance, ensuring timely incontinent care, maintaining sufficient staffing levels, securing medications properly, and holding required quarterly Quality Assurance meetings.
Deficiencies (8)
Failed to maintain a clean, comfortable environment as evidenced by broken window blinds, dirty bed rails, walls, call light cords, trash receptacles, and feeding pumps in multiple hallways.
Failed to implement care plans related to Activities of Daily Living (ADL) and incontinent care for residents, resulting in actual harm.
Failed to provide Activities of Daily Living (ADL) care and incontinent care for dependent residents.
Failed to provide timely incontinent care to heal skin breakdown for reoccurring Stage II pressure ulcers.
Failed to ensure sufficient nursing staff to provide adequate care and assistance for residents for 23 of 28 days reviewed.
Failed to ensure a medication cart was locked and medications were secured, leaving medications unattended.
Failed to store, prepare, and serve foods in a sanitary manner and provide a safe and clean environment, including a dirty oven and crumbling ceiling tiles over a preparation table.
Failed to hold quarterly Quality Assurance (QA) meetings for two of four quarters reviewed.
Report Facts
Residents on duty: 108
Days short staffed: 23
Scheduled CNAs: 8
Actual CNAs working: 2
Pressure ulcer wound size: 7.1
Pressure ulcer wound size: 2.7
Pressure ulcer wound size: 11.2
Pressure ulcer wound size: 2.8
Staffing ratio low: 1.83
Staffing ratio low: 1.9
Staffing ratio low: 1.94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Observed locking medication cart and working medication cart on B side |
| LPN #6 | Licensed Practical Nurse | Left medication cart unlocked with medications on top |
| DON | Director of Nursing | Confirmed skin breakdown on Resident #105 and staffing issues |
| Administrator | Facility Administrator | Aware of staffing challenges and QA meeting requirements |
| CNA #9 | Certified Nursing Assistant | Reported working short staffed with only one CNA on A side |
| CNA Supervisor | Certified Nursing Assistant Supervisor | Responsible for CNA scheduling, confirmed staffing shortages |
| RN #2 | Registered Nurse | Wound care nurse for Resident #105 |
| RN #1 | Registered Nurse | Unit Manager, confirmed importance of mouth care |
| CNA #1 | Certified Nursing Assistant | Observed delayed incontinent care for Resident #105 |
| DM #1 | Dietary Manager | Confirmed food safety issues and kitchen cleanliness problems |
Inspection Report — Aug 23, 2022
Complaint Investigation
Date: Aug 23, 2022
Visit Reason
The State Agency conducted an onsite complaint investigation for allegations of abuse and neglect of residents by staff.
Complaint Details
Complaint investigations for MS00019497, MS00019433, and MS00019447 regarding allegations of abuse and neglect were not substantiated.
Findings
The State Agency was not able to substantiate the allegations and no deficiencies were cited. The facility was determined to be in substantial compliance with the requirements for The Aged and Infirmed.
Report Facts
Inspection Report — Oct 8, 2021
Routine
Date: Oct 8, 2021
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 10/08/2021 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with all requirements and no deficiencies were cited during the survey.
Report Facts
Licensed beds: 119
Inspection Report — Oct 8, 2021
Routine
Date: Oct 8, 2021
Visit Reason
A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 10/08/2021 to assess compliance with 42 CFR 483.73 related to emergency preparedness.
Findings
The facility was found to be in compliance with the applicable emergency preparedness requirements during the survey.
Inspection Report — Sep 20, 2021
Complaint Investigation
Date: Sep 20, 2021
Visit Reason
A Complaint Investigation (CI) for CI #18075 was conducted on 9/17/21 and 9/20/21 for allegations of neglect, staffing, and abuse.
Complaint Details
Complaint Investigation for allegations of neglect, staffing, and abuse; allegations were unsubstantiated with no deficiencies cited.
Findings
The surveyor determined that the facility was in compliance with Medicare and Medicaid requirements. The allegations were unsubstantiated and no deficiencies were cited.
Inspection Report — Jul 7, 2021
Complaint Investigation
Date: Jul 7, 2021
Visit Reason
The State Agency conducted a complaint survey at the facility from 7/6/21 to 7/7/21 to investigate multiple complaints including dignity, quality of care, pain medication, weight loss assessment, rehabilitation services, feeding assistance, telephone use, and staffing.
Complaint Details
Complaints investigated included dignity, quality of care, pain medication, weight loss assessment, rehabilitation services, assessment and monitoring, inappropriate feeding assistance, telephone use, and staffing. None were substantiated.
Findings
The State Agency determined the facility was in compliance with Medicare and Medicaid requirements, did not substantiate the complaints, and cited no deficiencies.
Report Facts
Licensed beds: 119
Inspection Report — Aug 25, 2020
Routine
Date: Aug 25, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/25/20 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.
Report Facts
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 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 — May 29, 2020
Routine
Date: May 29, 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 to prepare for COVID-19.
Inspection Report — May 29, 2020
Abbreviated Survey
Date: May 29, 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.
Report Facts
Inspection Report — Jan 14, 2020
Complaint Investigation
Date: Jan 14, 2020
Visit Reason
The State Agency conducted a complaint survey investigating concerns related to Resident Rights and Patient care regarding Pressure Ulcers for Resident #1.
Complaint Details
The complaint investigation was related to allegations of Resident Rights and Patient care concerning Pressure Ulcers for Resident #1, which were not substantiated.
Findings
The concerns were not substantiated, no deficiencies were cited, and the facility was found to be in substantial compliance with Medicare and Medicaid requirements.
Inspection Report — Oct 23, 2019
Annual Inspection
Date: Oct 23, 2019
Visit Reason
The inspection was an annual licensure survey conducted from 10/20/19 to 10/23/19, combined with complaint investigations for MS #16161, MS #16246, and MS #16293.
Complaint Details
The survey included complaints MS #16161, MS #16246, and MS #16293. The complaint MS #16293 related to environment and staffing was substantiated and cited. Complaints MS #16161 and MS #16246 related to Quality of Care and misappropriation were not substantiated.
Findings
The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, with deficiencies related to inadequate assistance with activities of daily living (specifically nail care for dependent residents) and failure to maintain a sanitary and odor-free environment in parts of the facility.
Deficiencies (2)
Failure to provide adequate Activities of Daily Living (ADL) care, specifically nail care, to dependent residents as evidenced by dirty, long, jagged, and unkept fingernails and toenails for four of five residents reviewed.
Failure to ensure a sanitary and safe environment free of odors for two of four halls and the building entrance, evidenced by odors of urine/feces, overflowing linen barrels, and debris on a resident's floor.
Report Facts
Number of dependent residents reviewed for ADL needs: 5
Number of residents with nail care deficiencies: 4
Number of halls with odor issues: 2
Number of housekeeping staff: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding diabetic nail care and facility compliance |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Conducted education and quality reviews related to nail care and sanitary environment |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed about nail care provided to Resident #60 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Interviewed and measured Resident #62's toenails |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Confirmed nail care deficiencies for Resident #52 and Resident #196 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Interviewed about odor issues and housekeeping |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Observed odor issues and linen barrel overflow |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Described nail care practices and communication with nurses |
| Certified Nursing Assistant #4 | Certified Nursing Assistant (CNA) | Assigned to Resident #62 and described nail care and hospice involvement |
| Housekeeping Supervisor | Housekeeping Supervisor (HS) | Interviewed about housekeeping staffing and odor control efforts |
| Unit Coordinator/RN #1 | Registered Nurse (RN) | Described nail care responsibilities and podiatrist referrals |
| Administrator | Administrator | Confirmed odor issues and housekeeping staffing levels |
Inspection Report — Oct 21, 2019
Annual Inspection
Date: Oct 21, 2019
Visit Reason
Annual recertification survey combined with complaint investigations related to environment, staffing, quality of care, and misappropriation.
Complaint Details
Complaints MS#16161, MS#16246, and MS#16293 were investigated. MS#16293 was substantiated related to environment and staffing. MS#16161 and MS#16246 related to quality of care and misappropriation were not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to PASARR screening, comprehensive care plans, ADL care including nail care, nurse staffing posting, sanitary environment, sprinkler system coverage, hazardous area enclosures, and corridor door smoke resistance.
Deficiencies (9)
Failure to accurately complete Level I Pre-Admission Screening (PAS) for mental health diagnosis and psychotropic medication use for 2 of 11 residents reviewed.
Failure to follow comprehensive care plans related to nail care for 3 of 5 residents reviewed.
Failure to revise comprehensive care plans timely related to nail care and medication changes for 2 of 31 care plans reviewed.
Failure to provide necessary ADL care including nail care for 4 of 5 dependent residents reviewed.
Failure to post daily nurse staffing information in a visible location for residents and visitors; staffing data not current for 1 of 4 days observed.
Failure to maintain a safe, functional, sanitary, and comfortable environment free of odors and with proper housekeeping in 2 of 4 halls and building entrance.
Ceiling damage in Beauty Shop and Kitchen Storage Area compromising fire/smoke barrier integrity.
Lack of sprinkler head and coverage in newly installed office in Reception Area.
Corridor doors with air transfer grille and doors incapable of closing and positive latching, failing to resist passage of smoke.
Report Facts
Residents reviewed for PAS: 11
Residents reviewed for ADL care: 5
Care plans reviewed: 31
Residents affected by sprinkler deficiency: 26
Residents affected by hazardous area deficiency: 20
Residents affected by corridor door deficiency: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Responsible for completing PAS screenings; identified inaccurate PAS completion |
| Director of Nurses | Director of Nurses (DON) | Assessed residents for negative outcomes, confirmed care plan deficiencies, and responsible for nail care oversight |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Educated staff on PAS completion and care plan adherence |
| Licensed Practical Nurse #3 | LPN | Confirmed observations of residents' nail conditions |
| Certified Nursing Assistant #2 | CNA | Reported odor issues and housekeeping concerns |
| Maintenance Director | Maintenance Director | Responsible for repairs related to fire safety deficiencies |
| Executive Director | Executive Director (ED) | Oversaw quality reviews and corrective actions |
7 CMS Surveys
CMS Survey — Mar 14, 2023
Mar 14, 2023
CMS Survey — Nov 8, 2023
Nov 8, 2023
CMS Survey — Jul 2, 2024
Jul 2, 2024
CMS Survey — Jan 5, 2026
Jan 5, 2026
CMS Survey — Oct 19, 2022
Oct 19, 2022
CMS Survey — Feb 6, 2024
Feb 6, 2024
CMS Survey — Sep 10, 2025
Sep 10, 2025
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