Inspection Reports for The Nichols Center

The State Agency conducted a follow-up revisit at the facility on 12/10/2025 related to a complaint survey conducted on 10/22/2025 to determine if corrective measures were implemented.

The facility corrected the deficiencies cited in the 10/22/2025 complaint survey as of 11/08/2025, but remained out of compliance with Medicare and Medicaid participation requirements until 12/06/2025.

The visit was a follow-up related to a complaint survey conducted on 10/22/2025. The corrective measures were found to be effective as of 11/08/2025.

The State Agency conducted a follow-up revisit at the facility on 12/10/2025 related to a complaint survey conducted on 10/22/2025 to verify corrective measures taken by the facility.

The facility corrected the deficiencies cited on the 10/22/2025 survey as of 11/08/2025, but remained out of compliance with state licensure requirements until 12/06/2025, the compliance date for the 11/25/2025 survey.

The follow-up revisit was related to a complaint survey conducted on 10/22/2025.

The State Agency conducted a follow-up revisit at the facility on 12/10/2025 related to a complaint survey conducted from 11/24/2025 to 11/25/2025.

The State Agency determined the facility was in compliance with Medicare and Medicaid participation requirements and recommends the facility be placed back in compliance effective 12/06/2025.

The follow-up revisit was related to a complaint survey conducted on 11/24/2025-11/25/2025. The facility was found to be in compliance upon revisit.

The State Agency conducted a follow-up revisit at the facility related to a complaint survey conducted from 2025-11-24 to 2025-11-25.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions of the Aged and Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 2025-12-06.

The visit was related to a complaint survey conducted from 2025-11-24 to 2025-11-25. The facility was found to be in compliance upon follow-up.

The State Agency conducted complaint investigations at the facility from 11/24/25 through 11/25/25 related to allegations of failure to protect resident rights.

The facility was found non-compliant for failure to ensure a resident was treated with dignity and respect. Two Certified Nursing Assistants were found to have mistreated Resident #1, resulting in their termination.

The complaint investigations #2637343 and #2642737 substantiated failure to protect resident rights. No deficiencies were cited for complaint investigation #2650460.

The State Agency conducted complaint investigations #2637343, #2642737, and #2650460 at the facility from 11/24/25 through 11/25/25 to determine compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.

The facility was found non-compliant for failure to protect resident rights related to one resident out of four reviewed. Two Certified Nursing Assistants (CNAs) were found to have treated Resident #1 without dignity and respect, resulting in their termination.

Complaint investigations #2637343 and #2642737 were substantiated for failure to protect resident rights. Complaint investigation #2650460 had no deficiencies cited.

The State Agency conducted an onsite facility reported incident investigation for Incident #2607111 at the facility on 10/22/2025.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to ensure resident safety during mechanical lift transfers. Specifically, staff failed to assess and use the appropriate sling and did not inspect the sling for wear or damage, resulting in a resident fall causing a lumbar compression fracture and skin abrasion.

The investigation was triggered by a reported incident where Resident #1 fell approximately three feet from a mechanical lift due to use of an incorrect and uninspected sling. The fall caused a skin abrasion and an L1 lumbar compression fracture. Staff interviews confirmed failure to assess sling appropriateness and condition. The sling used was not provided by the facility's lift company and was in poor condition. Staff involved were terminated.

The State Agency conducted an onsite facility reported incident investigation for Incident #2607111 at the facility on 10/22/2025.

The facility failed to ensure resident safety during mechanical lift transfers by failing to assess and use the appropriate sling and by failing to inspect the sling for signs of wear or damage prior to use, resulting in a resident fall causing a lumbar compression fracture and skin abrasion.

The investigation was triggered by a reported incident where Resident #1 fell approximately three feet from a total lift due to use of an incorrect and uninspected sling, resulting in a lumbar compression fracture and skin abrasion. Staff failed to assess the resident and sling properly, and the sling used was not provided by the facility's lift company and was in poor condition. Staff involved were terminated.

The State Agency conducted complaint investigations related to pressure sores, grooming and hygiene, environment, dignity, staffing, and food service at the facility.

The facility was found to be in compliance with Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements, with no deficiencies cited.

Complaint investigations (CI MS #27859 and CI MS #28637) were conducted with no deficiencies cited.

The State Agency conducted complaint investigations at the facility on 5/13/2025 related to pressure sores, grooming and hygiene, environment, dignity, staffing, and food service.

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

Complaint Investigations CI MS #27859 and CI MS #28637 were conducted with no deficiencies cited.

The State Agency conducted multiple complaint investigations at the facility from 2025-02-04 through 2025-02-05 to investigate quality of care/treatment, resident assessment, falls, infection control, staffing, environment, and activities of daily living.

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

The complaint investigations included CI #26779, CI MS #27442, CI MS #27586, CI MS #27619, and CI MS #27659. The facility was found compliant with no deficiencies.

The State Agency conducted complaint investigations at the facility from 2025-02-04 through 2025-02-05 to investigate quality of care/treatment, resident assessment, falls, infection control, staffing, environment, and activities of daily living.

The facility was found to be in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements, with no deficiencies cited.

Complaint Investigations #26779, #27442, #27586, #27619, and #27659 were conducted and found no deficiencies.

The State Agency conducted an onsite complaint investigation for alleged verbal abuse of a resident.

The facility was found to be in compliance with the Standards for participation in Medicare and Medicaid, and no deficiencies were cited.

Complaint investigation (CI MS #25454) for alleged verbal abuse of a resident; no deficiencies were cited.

The State Agency conducted an onsite complaint investigation for alleged verbal abuse of a resident.

The facility was found to be in compliance with the Requirements for the Aged and Infirmed and no deficiencies were cited.

Complaint investigation MS #25454 for alleged verbal abuse of a resident; no deficiencies were cited.

The State Agency conducted a desk review of information related to the annual survey completed on 2024-03-14 to verify corrective measures and compliance with Medicare and Medicaid requirements.

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 2024-04-15.

The State Agency conducted an annual recertification survey and a complaint investigation (CI) MS #24191 at the facility from 3/11/24 through 3/14/24.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, including compliance related to complaint investigation MS #24191 for facility staffing.

Complaint investigation MS #24191 was conducted and the facility was found in compliance related to facility staffing.

The State Agency conducted an annual recertification survey and a complaint investigation at the facility from 3/11/24 through 3/14/24 to determine compliance with Medicare and Medicaid requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to comprehensive care plans, professional standards of services provided, and psychotropic medication use. No deficiencies were cited related to facility staffing.

Complaint investigation (Cl MS #24191) was conducted concurrently with the annual survey. The facility was found in compliance related to facility staffing with no deficiencies cited.

The State Agency conducted an annual recertification survey and a complaint investigation at the facility from 2024-03-11 through 2024-03-14.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. The complaint investigation related to facility staffing was also determined to be in compliance.

Complaint investigation MS #24191 related to facility staffing was found to be in compliance.

The State Agency conducted an annual recertification survey and a complaint investigation at the facility from 3/11/24 through 3/14/24.

The facility was found not in compliance with Medicare and Medicaid requirements, with cited deficiencies at F656, F658, and F758. The facility was found in compliance related to facility staffing with no deficiencies cited for the complaint investigation.

Complaint investigation (Cl MS #24191) was conducted and the facility was found in compliance related to facility staffing with no deficiencies cited.

The State Agency conducted a desk review of information related to the annual survey completed on 03/14/24 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was confirmed to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm based on the information provided during the desk review.

The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable emergency preparedness requirements with no deficiencies cited during the survey.

The State Agency conducted a desk review of information related to a complaint survey completed on 2023-12-18 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2024-01-26.

The visit was related to a complaint survey completed on 2023-12-18. The facility was found to be in compliance based on the desk review.

The State Agency conducted a desk review related to a complaint survey completed on 2023-12-18 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices, sustaining compliance with Medicare and Medicaid requirements. The State Agency recommends the facility be placed back in compliance effective 2024-01-26.

The visit was complaint-related, reviewing corrective actions following a complaint survey from 2023-12-18. The facility was found to have corrected deficiencies and sustained compliance.

The State Agency conducted a complaint investigation from 2024-01-08 through 2024-01-10 related to Quality of Care/treatment services following a prior incident involving a resident fall from a total lift.

The facility failed to protect a resident's right to be free from neglect when a resident was transferred using a total lift without the required two staff members, resulting in the lift overturning and the resident falling with injuries. The facility was found out of compliance due to deficiencies cited on a prior survey and corrective actions were implemented before this survey.

Complaint Investigation for CI MS#23773 regarding Quality of Care/treatment services. The deficiency was determined to be Past Non-Compliance based on corrective actions taken on 2023-12-21 prior to survey entrance. The incident involved a resident fall from a total lift on 2023-12-06, resulting in skin tears and hematoma, requiring emergency room transfer. The CNA involved was suspended and terminated. Facility implemented retraining and monitoring.

The State Agency conducted a complaint investigation at the facility from 1/8/24 through 1/10/24 related to Quality of Care/treatment services.

The facility failed to protect a resident from neglect when a CNA attempted to transfer a resident using a total lift without the required two staff members, resulting in the lift overturning and the resident falling with injuries. The facility was found out of compliance due to deficiencies cited in a prior survey and corrective actions were implemented prior to this investigation.

The complaint investigation (CI MS#23773) was triggered by concerns about Quality of Care/treatment services. The investigation found past non-compliance related to a resident fall from a total lift due to staff neglect. The CNA involved was suspended and terminated. The facility implemented corrective actions including staff retraining and monitoring.

The State Agency conducted a Complaint Investigation at the facility for CI MS #23578 from 12/17/23 through 12/18/23 regarding misappropriation of property by a nurse.

The facility failed to prevent diversion of controlled substances by an LPN who was observed on video taking and consuming liquid morphine from the narcotic box belonging to Resident #1. The LPN tested positive for multiple substances and was terminated and arrested. The facility implemented corrective actions including staff in-services and increased narcotic audits.

The complaint investigation was triggered by Resident #4 reporting that LPN #1 was acting 'tired'. Video surveillance confirmed diversion of narcotics by LPN #1. The LPN denied medication use initially but tested positive for marijuana, opiates/morphine, amphetamines, and benzodiazepines. The incident was reported to the Board of Nursing, Licensing State Agency, local police, Attorney General office, and Board of Pharmacy. LPN #1 was arrested and terminated.

The State Agency conducted a Complaint Investigation at the facility from 12/17/23 through 12/18/23 due to allegations of misappropriation of property involving controlled substances by a nurse.

The facility failed to prevent misappropriation of controlled substances by a Licensed Practical Nurse (LPN #1) who was observed on video surveillance diverting liquid morphine belonging to Resident #1. The nurse tested positive for multiple drugs and was terminated and reported to authorities. The facility implemented corrective actions including staff in-service training and increased monitoring.

The complaint investigation was triggered by Resident #4 reporting concerns about a male nurse acting tired. The investigation revealed diversion of controlled substances by LPN #1, who was subsequently suspended, tested positive for drugs, reported to multiple agencies, and arrested.

The State Agency conducted a Complaint Investigation CI MS #23291 at the facility on 12/6/23 through 12/7/23 to investigate discharge rights.

The facility was found to be in compliance with the Minimum Standards of Operations for the Institutions of Aged or Infirm, with no deficiencies cited related to discharge rights.

Complaint Investigation CI MS #23291 regarding discharge rights was investigated with no deficiencies cited.

The State Agency conducted a Complaint Investigation at the facility on 12/6/23 through 12/7/23 to investigate discharge rights.

The facility was found to be in compliance with Medicare and Medicaid participation requirements, with no deficiencies cited related to discharge rights.

Complaint Investigation (CI MS #23291) was conducted with no deficiencies cited and discharge rights investigated.

The State Agency conducted a complaint survey from 7/12/23 through 7/13/23 to investigate complaint MS #21848 regarding sufficient staffing.

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.

Complaint MS #21848 regarding sufficient staffing was investigated and found to be unsubstantiated with no deficiencies cited.

The State Agency conducted a complaint investigation (CI MS# 21848) at the facility from 7/12/23 through 7/13/23.

The facility was found to be in compliance with Medicare and Medicaid Services requirements. No deficiencies were cited related to the complaint regarding sufficient staffing.

Complaint investigation CI MS# 21848 was conducted and found no substantiated deficiencies related to sufficient staffing.

The State Agency conducted a desk review of information related to the annual survey completed on 2022-12-01 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed that the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.

The State Agency conducted a desk review of information related to the annual survey completed on 2022-12-01 to verify corrective measures taken by the facility.

The information provided confirmed that the facility had implemented measures to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility is recommended to be placed back in compliance effective 2023-01-06.

The State Agency conducted an annual recertification survey at the facility from 11/28/22 through 12/1/22 to assess compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.

The facility was found to be in compliance with no deficiencies cited during the annual recertification survey.

The State Agency conducted an annual recertification survey at the facility from 11/28/22 through 12/01/22 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance due to deficiencies related to respiratory care, specifically failure to date oxygen, nebulizer tubing, and humidifier bottles, and failure to place oxygen signage on resident doors for three residents. Additionally, two residents lacked physician orders for oxygen therapy.

The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable emergency preparedness requirements with no deficiencies cited.

The State Agency conducted an onsite complaint investigation for alleged abuse and neglect of a former resident.

The complaint was unsubstantiated, no deficiencies were cited, and the facility was found to be in substantial compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.

Complaint investigation CI MS #19368 was unsubstantiated with no deficiencies cited.

The State Agency conducted an onsite complaint investigation for alleged abuse and neglect of a former resident.

The complaint investigation was unsubstantiated, no deficiencies were cited, and the facility was found to be in substantial compliance with Medicare and Medicaid participation standards.

Complaint investigation CI MS #19368 for alleged abuse and neglect of a former resident was unsubstantiated.

The State Agency conducted a complaint survey from 5/31/22 through 6/1/22 in response to a complaint regarding safety/falls, residents not groomed, residents left wet, and medications not given as ordered for Resident #1.

The complaint was not substantiated. 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.

Complaint survey MS #18051 was conducted; the complaint was not substantiated.

The State Agency conducted a complaint survey at the facility from 2022-05-31 through 2022-06-01 to investigate allegations related to safety/falls, residents not groomed, residents left wet, and medications not given as ordered for Resident #1.

The complaint was not substantiated. The facility was found to be in compliance with Medicare and Medicaid participation requirements.

Complaint survey MS#18051 was conducted. The complaint regarding safety/falls, residents not groomed, residents left wet, and medications not given as ordered was not substantiated.

The State Agency conducted a complaint survey on 7/22/21 for MS CI #17915 regarding allegations of resident denied visitation/access rights and resident not being treated with dignity and respect.

The State Agency determined the facility was not in compliance with Mississippi regulations for Minimum Standards for Institutions for Aged or Infirm but did not substantiate the complaint and cited no deficiencies.

Complaint MS #17915 for Resident denied visitation/access rights and Resident not being treated with dignity and respect was not substantiated.

The State Agency conducted a complaint survey on 7/22/21 to investigate allegations related to resident visitation rights and treatment with dignity and respect.

The survey determined the facility was in compliance with Medicare and Medicaid participation requirements, did not substantiate the complaint regarding denied visitation and dignity, and cited no deficiencies.

Complaint MS #17915 regarding resident denied visitation and access rights and resident not treated with dignity and respect was not substantiated.

The State Agency conducted a complaint survey from 6/7/21 to 6/9/21 to investigate multiple complaints related to infection control, resident neglect, quality of care, staffing, and rehabilitation services.

The State Agency did not substantiate the complaints regarding infection control, resident neglect, quality of care, staffing, rehabilitation services, and water not offered to a resident, with no citations issued.

Complaints MS #17458, MS #17438, and MS #17419 were investigated and not substantiated by the State Agency.

The State Agency conducted a complaint survey from 6/7/21 through 6/9/21 to investigate multiple complaints regarding resident neglect, quality of care, infection control, and facility staffing.

The facility was found to be in compliance with Medicare and Medicaid participation requirements. None of the complaints were substantiated and no deficiencies were cited.

Complaints investigated included Resident neglect to assess and monitor, Quality of Care for improper infection control and water not offered, Resident neglect for medications, Quality of Care for residents left soiled, improper infection control, facility staffing, rehabilitation services, and infection control for COVID and phone answering issues. None were substantiated.

The State Agency conducted a complaint survey from 6/7/21 to 6/9/21 related to multiple complaints including infection control, resident neglect, quality of care, staffing, and rehabilitation services.

The State Agency did not substantiate the complaints regarding infection control, resident neglect, quality of care, staffing, rehabilitation services, and water not offered to residents, with no citations issued.

Complaints MS #17458, MS #17348, and MS #17419 were investigated and not substantiated.

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.

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.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 11/17/20 to assess compliance with relevant regulations.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.

A COVID-19 Focused Infection Control Survey and a complaint investigation were conducted by the State Agency on 9/11/20.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. The complaint investigation was unsubstantiated with no deficiencies cited, and the facility was in compliance with Medicare and Medicaid requirements.

The complaint investigation conducted on 9/11/20 was unsubstantiated with no deficiencies cited.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

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

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.

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.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 7/7/20 to assess compliance with infection control regulations and preparedness for COVID-19.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The State Agency conducted a licensure survey along with a complaint survey from 12/2/19 to 12/4/19 to investigate complaint Cl MS #00016357.

The complaint was substantiated, but no deficiencies were cited related to the complaint. The facility was found not in compliance with State Licensure Regulations for the Aged or Infirm and cited State Statute M815.

Complaint survey Cl MS #00016357 was substantiated, but no deficiencies were cited related to the complaint.

The State Agency conducted an annual recertification survey along with a complaint investigation from 12/2/19 to 12/4/19. The complaint was substantiated for misappropriation of property with no citations related to the complaint. The survey also assessed compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with several regulatory requirements including comprehensive care plan development and revision, medication administration standards, and food safety practices. Deficiencies were cited related to care planning for medications and nutrition, improper administration of inhalers, and inadequate food storage and sanitation.

Complaint investigation CI MS #00016357 was substantiated for misappropriation of property but no citations were related to the complaint.

The State Agency conducted a licensure survey along with a complaint survey (CI MS #00016357) from 12/2/19 to 12/4/19. The complaint was substantiated but no deficiencies were cited related to the complaint. The survey also assessed compliance with State Licensure Regulations for the Aged or Infirm.

The facility failed to follow proper sanitation and food storage procedures to prevent the likelihood of food borne illness during dietary tours. Observations included improperly stored, unlabeled, and undated food items, unsanitary microwave conditions, improper glove use, and cross-contamination risks. Corrective actions included immediate disposal of unsafe food, staff in-service training, and implementation of monitoring procedures.

The complaint survey CI MS #00016357 was substantiated, but no deficiencies were cited related to the complaint itself.

The State Agency conducted an annual recertification survey along with a complaint investigation from 12/2/19 to 12/4/19.

The complaint investigation substantiated misappropriation of property with no citations related to the complaint. The facility was found not in compliance with Medicare and Medicaid participation requirements, with citations issued for F656, F657, F658, and F812.

Complaint investigation CI MS #00016357 substantiated for misappropriation of property with no citations related to the complaint.

A complaint investigation was conducted on April 30, 2019 at The Nichols Center.

The investigation was unsubstantiated with no deficiencies cited.

The complaint investigation was unsubstantiated with no deficiencies cited.