Inspection Reports for
Tallahatchie General Hospital Extended Care
201 South Market Street, Charleston, MS, 38921
Back to Facility Profile28 Reports
Inspection Report — Apr 7, 2026
Complaint Investigation
Date: Apr 7, 2026
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI MS #2968412) at the facility on 04/07/26.
Complaint Details
Complaint investigation CI MS #2968412 found the facility in compliance with no deficiencies cited.
Findings
The survey determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid Services and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 9, 2025
Annual Inspection
Date: Dec 9, 2025
Visit Reason
On 12/09/25 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 10/29/25.
Findings
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. The SA is recommending that your facility be placed back in compliance effective 12/02/25.
Report Facts
Deficiencies cited: 0
Inspection Report — Oct 30, 2025
Life Safety
Date: Oct 30, 2025
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this survey.
Inspection Report — Oct 29, 2025
Annual Inspection
Date: Oct 29, 2025
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 10/27/25 through 10/29/25. During the survey, the SA determined that the facility was not in compliance with the Medicare and Medicaid regulations for participation and cited regulatory deficiencies F558, F697, and F880. The SA also investigated complaint investigations (CI) 2653611 and CI 2601612 with no deficiencies cited in regard to the allegations in the complaints.
Complaint Details
Complaint investigations CI 2653611 and CI 2601612 were investigated with no deficiencies cited in regard to the allegations.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations, citing deficiencies in reasonable accommodations, pain management, and infection prevention and control. No deficiencies were found related to the complaint investigations.
Deficiencies (3)
F0558 - Reasonable accommodations needs/preferences. The facility failed to ensure the call light was within reach for one resident, resulting in lack of access to staff assistance when needed.
F0697 - Pain management. The facility failed to ensure an active order for as needed pain medication was available when required for one resident, causing delayed medication administration and resident distress.
F0880 - Infection prevention and control. The facility failed to maintain infection control practices for two residents, including improper storage of suction supplies and failure to use enhanced barrier precautions during medication administration.
Report Facts
Deficiencies cited: 3
Inspection Report — Jun 17, 2025
Complaint Investigation
Date: Jun 17, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI) MS #28774 and CI #29028 at the facility on 06/17/25.
Complaint Details
Complaint investigation numbers MS #28774 and MS #29028 were conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm and there were no deficiencies cited.
Report Facts
Complaint investigations: 2
Inspection Report — Jan 15, 2025
Annual Inspection
Date: Jan 15, 2025
Visit Reason
On 1/15/25 the State Agency conducted a desk review of information related to the annual survey completed on 12/04/24. The facility confirmed it had put measures 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 01/08/25. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 15, 2025
Date: Jan 15, 2025
Visit Reason
On 01/15/25 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 12/04/24.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Inspection Report — Dec 4, 2024
Annual Inspection
Date: Dec 4, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 12/02/24 through 12/04/24. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation and cited regulatory deficiencies at F583, F641, F656, F677, and F761.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in resident privacy, accuracy of assessments, comprehensive care planning, provision of ADL care, and medication storage security.
Deficiencies (5)
F0583 - Personal privacy/confidentiality of records. The facility failed to ensure resident information was not accessible to the public during medication administration for one resident, as an open computer screen displayed personal health information.
F0641 - Accuracy of assessments. The facility failed to accurately complete a section of the Minimum Data Set (MDS) reflecting significant weight loss for one resident.
F0656 - Develop/implement comprehensive care plan. The facility failed to develop and implement an Activities of Daily Living (ADL) comprehensive care plan for hygiene, grooming, and nail care for two residents.
F0677 - ADL care provided for dependent residents. The facility failed to provide nail care to maintain personal hygiene for two residents, resulting in long, jagged nails with debris.
F0761 - Label/store drugs and biologicals. The facility failed to properly secure medications by leaving a medication cart unlocked and unattended during medication administration.
Report Facts
Deficiencies cited: 5
Inspection Report — Dec 3, 2024
Life Safety
Date: Dec 3, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Feb 15, 2024
Complaint Investigation
Date: Feb 15, 2024
Visit Reason
The State Agency conducted an on site complaint investigation (CI) for a facility reported incident, CI MS #23719, which alleged that a facility staff member had verbally abused a resident after a fall with no injuries on 2/15/24.
Complaint Details
CI MS #23719 alleged verbal abuse by a facility staff member to a resident after a fall. The complaint was substantiated with deficiencies cited at M500 for Resident Rights at a Level II Past Non Compliance (PNC).
Findings
The facility was found to have an isolated incident of verbal abuse to Resident #1 by a Certified Nursing Assistant (CNA #1) on 12/19/23. The facility implemented corrective actions and the deficiency was fully corrected on 12/21/23 prior to the State Agency's entrance on 02/15/24.
Deficiencies (1)
M500 - Residents' Rights. The facility failed to prevent verbal abuse of Resident #1 by a Certified Nursing Assistant, which was confirmed by multiple staff and resident interviews and documented investigation.
Report Facts
Deficiencies cited: 1
Inspection Report — Sep 27, 2023
Follow-Up
Date: Sep 27, 2023
Visit Reason
The State Agency conducted a revisit survey on 9/27/23 for an annual survey that was conducted on 8/24/23.
Findings
The SA determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Inspection Report — Aug 24, 2023
Annual Inspection
Date: Aug 24, 2023
Visit Reason
The State Agency conducted an Annual Re-certification Survey at the facility from 8/21/23 through 8/24/23. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid Services.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in notice requirements before transfer/discharge, development and implementation of comprehensive care plans, and treatment/services to prevent or heal pressure ulcers.
Deficiencies (3)
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to send a copy of transfer/discharge notices to the State Long-Term Care Ombudsman for three residents.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop a comprehensive care plan to prevent the recurrence of a pressure ulcer for a resident with a hand contracture.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to prevent the recurrence of a pressure ulcer related to a contracture of a resident's hand.
Report Facts
Deficiencies cited: 3
Inspection Report — Aug 22, 2023
Life Safety
Date: Aug 22, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Sep 6, 2022
Routine
Date: Sep 6, 2022
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements as specified by CMS and the CDC.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - 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 regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 4, 2022
Complaint Investigation
Date: Aug 4, 2022
Visit Reason
The State Agency conducted a complaint, CI MS #19446, from 8/4/22 to 8/4/22.
Complaint Details
Complaint number CI MS #19446 was investigated and found unsubstantiated; no deficiencies were cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited.
Report Facts
Complaints investigated: 1
Inspection Report — Mar 9, 2022
Annual Inspection
Date: Mar 9, 2022
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual survey conducted on 1/27/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 03/03/22. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 27, 2022
Annual Inspection
Date: Jan 27, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey in the facility from 1/24/22 through 1/27/22. The SA determined the facility was not in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged and Infirm and M 815 was cited for safe food handling procedures.
Findings
M815 - The facility failed to date and label foods in the walk-in refrigerator and dispose of expired foods during one of two kitchen tours. Observations included multiple expired and unlabeled food items, and interviews confirmed staff had not been following the facility policy for labeling food in the refrigerator.
Deficiencies (1)
M815 - Safe Food Handling Procedures. The facility failed to properly date and label foods and dispose of expired foods in the walk-in refrigerator during one of two kitchen tours.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 25, 2022
Life Safety
Date: Jan 25, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider. 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
There were no Life Safety Code deficiencies cited during this survey. The facility met the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Dec 15, 2021
Complaint Investigation
Date: Dec 15, 2021
Visit Reason
A Complaint Investigation (CI) was conducted 12/14/21-12/15/21 for CI #18060 and CI #18030. CI #18060 was an anonymous complaint with allegations regarding Injury of Unknown Origin. CI #18030 was a CI filed by a family member of a resident with allegations of inadequate staffing, Resident Rights, Improper Incontinent Care and Quality of Care/tx.
Complaint Details
Complaint Investigation CI #18060 was an anonymous complaint alleging Injury of Unknown Origin. Complaint Investigation CI #18030 was filed by a family member alleging inadequate staffing, Resident Rights, Improper Incontinent Care and Quality of Care/tx. Both complaints were unsubstantiated with no deficiencies cited.
Findings
The allegations were unsubstantiated with no deficiencies cited. During the survey, the facility was found to be in compliance with the requirements of participation for Medicare and Medicaid.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 15, 2020
Routine
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/15/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Dec 15, 2020
Routine
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 12/15/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Sep 15, 2020
Routine
Date: Sep 15, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 9/15/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Aug 3, 2020
Routine
Date: Aug 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/3/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 3, 2020
Routine
Date: Aug 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/3/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Jul 6, 2020
Routine
Date: Jul 6, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 7/6/20. 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.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited.
Inspection Report — Jul 6, 2020
Routine
Date: Jul 6, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/6/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — May 29, 2020
Routine
Date: May 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/29/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Sep 19, 2019
Annual Inspection
Date: Sep 19, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification along with a complaint, MS #16016 from 09/16/19 to 09/19/19.
Complaint Details
Complaint MS #16016 alleged lack of Registered Nurse coverage but was not substantiated; no citations related to the complaint were issued.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements and cited for deficiencies related to PEG tube medication administration, tube feeding management, and infection prevention and control. No deficiencies were cited for the complaint investigation regarding lack of RN coverage.
Deficiencies (3)
F0658 - Services Provided Meet Professional Standards. The facility failed to administer medications via PEG tube properly by not flushing between each medication for two residents, risking tube obstruction and medication toxicity.
F0693 - Tube Feeding Management/Restore Eating Skills. The facility failed to ensure appropriate procedures to prevent complications while administering medications via PEG tube, specifically not flushing between medications for two residents.
F0880 - Infection Prevention & Control. The facility failed to prevent spread of infection by contaminating gloves and a wound during care for one resident, as the nurse did not properly position the brief away from the wound, contaminating the wound and gloves.
Report Facts
Deficiencies cited: 3
Viewing
Loading inspection reports...
