Inspection Reports for
The Oaks Rehabilitation and Healthcare Center
3716 Highway 39 North, Meridian, MS, 39301
Back to Facility Profile58 Reports
Inspection Report — Jun 16, 2026
Complaint Investigation
Date: Jun 16, 2026
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 05/06/26-05/07/26. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint investigation completed on 05/06/26-05/07/26; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance as of 06/12/26 with no deficiencies cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 7, 2026
Complaint Investigation
Date: Jan 7, 2026
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #2693310 and MS #2695512, and a Facility Reported Incident (FRI) MS #2681525, at the facility from 1/5/26 through 1/7/26. MS #2693310 was investigated for allegations of infection control concerns, staff concerns, lack of clean linens and bathing supplies, and overall facility cleanliness. MS #2695512 was investigated for allegations of neglect and failure to provide care. FRI MS #2681525 was investigated for an allegation of abuse.
Complaint Details
Complaint Investigations MS #2693310 and MS #2695512 and Facility Reported Incident MS #2681525 were investigated for infection control, staff concerns, lack of clean linens and bathing supplies, overall cleanliness, neglect, failure to provide care, and abuse. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint Investigations: 2
Facility Reported Incident: 1
Inspection Report — Jan 7, 2026
Complaint Investigation
Date: Jan 7, 2026
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #2693310 and MS #2695512, and a Facility Reported Incident (FRI) MS #2681525, investigating infection control concerns, staff concerns, lack of clean linens and bathing supplies, overall facility cleanliness, neglect, failure to provide care, and an allegation of abuse.
Complaint Details
Complaint Investigations MS #2693310 and MS #2695512 and Facility Reported Incident MS #2681525 were investigated for infection control, staff concerns, cleanliness, neglect, failure to provide care, and abuse allegations. The facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations: 2
Facility Reported Incident: 1
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of abuse by a Certified Nursing Assistant (CNA) towards Resident #1.
Complaint Details
The complaint was substantiated. The investigation confirmed that the CNA made inappropriate comments to Resident #1 and that LPN #2 failed to report the allegation immediately. Corrective actions were taken including suspension and re-education of involved staff.
Findings
The facility failed to immediately notify the Administrator or designee of an abuse allegation by Licensed Practical Nurse (LPN) #2. The CNA admitted to making a joking comment threatening to spank the resident if he used his call light. Corrective actions included suspension of the CNA and LPN #2, in-service training on abuse reporting and professional communication, and a full body audit of the resident.
Deficiencies (1)
F 0607: The facility failed to implement its abuse prevention policy when LPN #2 did not immediately notify the Administrator or designee of an abuse allegation involving Resident #1. The CNA made a joking threat to spank the resident if he used his call light, which offended the resident.
Report Facts
Residents Affected: 3
Brief Interview for Mental Status (BIMS) score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to immediately notify Administrator of abuse allegation and was suspended |
| CNA #1 | Certified Nursing Assistant | Made joking threat to Resident #1 and was suspended pending investigation |
| LPN #1 | Licensed Practical Nurse | Reported the abuse allegation immediately to the Director of Nursing |
| DON | Director of Nursing | Received abuse allegation and initiated investigation |
| RDCS | Regional Director of Clinical Services | Confirmed corrective actions and expectations for abuse reporting |
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2584908, at the facility on 11/19/25 regarding an allegation of verbal abuse.
Complaint Details
CI MS#2584908 investigated an allegation of verbal abuse. The deficiency was substantiated but determined to be Past Non-Compliance and corrected prior to the survey.
Findings
The facility was found not in compliance due to failure to implement its abuse prevention policy when Licensed Practical Nurse (LPN) #2 did not immediately notify the Administrator or designee of an abuse allegation involving Resident #1. Corrective actions were implemented on 8/7/25, and the deficiency was determined to be Past Non-Compliance and corrected prior to the survey.
Deficiencies (1)
F0607 - The facility failed to implement its abuse prevention policy when LPN #2 did not immediately notify the Administrator or designee of an abuse allegation involving Resident #1.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 12, 2025
Life Safety
Date: Aug 12, 2025
Visit Reason
On 08/12/25 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 06/23/25. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code.
Findings
The facility was found to be in compliance with the Life Safety Code requirements as of 08/01/25. No deficiencies were cited during this desk review.
Inspection Report — Aug 6, 2025
Date: Aug 6, 2025
Visit Reason
On 08/06/25 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 6/26/25. 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 State Agency is recommending that the facility be placed back in compliance effective 8/1/25. No deficiencies were cited in this desk review.
Inspection Report — Aug 4, 2025
Complaint Investigation
Date: Aug 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2569608, at the facility on 8/4/25. MS #2569608 was investigated for staffing and medication error.
Complaint Details
Complaint Investigation (CI), MS #2569608, was investigated for staffing and medication error and was found to be in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Aug 4, 2025
Complaint Investigation
Date: Aug 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2569608, at the facility on 8/4/25. MS #2569608 was investigated for staffing and medication error.
Complaint Details
Complaint number CI MS #2569608 was investigated for staffing and medication error. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Jun 26, 2025
Annual Inspection
Date: Jun 26, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey and Complaint Investigation(CI), MS #28879, at the facility from 6/23/25 through 6/26/25. The SA investigated CI MS #28879 for quality of care related to treatment, and physical environment. There were no deficiencies cited related to the complaint investigation. During the annual recertification survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F558, F686, F690, F812, F867, and F880.
Complaint Details
CI MS #28879 investigated for quality of care related to treatment and physical environment. No deficiencies were cited related to the complaint investigation.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements during the annual recertification survey. Deficiencies included failure to accommodate a legally blind resident's call light needs, inadequate ADL care for dependent residents, insufficient wound care and skin integrity assessments, improper perineal care, unsafe food storage, and ineffective QAPI program implementation. Infection prevention and control practices were also deficient, risking resident safety.
Deficiencies (7)
F0558 - Reasonable accommodations needs/preferences. The facility failed to provide reasonable accommodation for a legally blind resident by not individualizing the call light system, leaving it out of reach and inaccessible.
F0677 - ADL care provided for dependent residents. The facility failed to provide necessary grooming and personal hygiene services, including nail trimming and facial hair removal, for a dependent resident.
F0686 - Treatment/services to prevent/heal pressure ulcer. The facility failed to ensure ongoing assessment and documentation of skin integrity for a high-risk resident, missing weekly skin integrity reviews.
F0690 - Bowel/bladder incontinence, catheter, UTI. The facility failed to provide perineal care according to professional standards, omitting cleansing of the vaginal area and proper hand hygiene, placing a resident at risk for urinary tract infection and skin breakdown.
F0812 - Food procurement, store/prepare/serve-sanitary. The facility failed to properly dispose of spoiled food and seal open food packages, risking foodborne illness.
F0867 - QAPI/QAA improvement activities. The facility failed to sustain an effective Quality Assurance Performance Improvement plan, resulting in a repeated deficiency related to inadequate ADL care.
F0880 - Infection prevention & control. The facility failed to provide perineal and wound care with proper hand hygiene and infection control practices, risking spread of infection.
Report Facts
Deficiencies cited: 7
Inspection Report — Jun 26, 2025
Annual Inspection
Date: Jun 26, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and quality of care at The Oaks Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to individualize a blind resident's call system, inadequate weekly skin integrity assessments, improper perineal care, poor food storage practices, ineffective quality assurance and performance improvement (QAPI) plan, and lapses in infection prevention and control practices.
Deficiencies (6)
F 0558: The facility failed to individualize the call light system for a blind resident, making it inaccessible and causing the resident to yell for assistance.
F 0686: The facility failed to perform and document weekly skin integrity reviews for a high-risk resident, compromising early detection of skin breakdown.
F 0690: Perineal care was not performed according to professional standards for a resident, omitting cleaning of the vaginal area and placing the resident at risk for urinary tract infection.
F 0812: The facility failed to properly dispose of moldy oranges and did not seal an open bag of food thickener, risking foodborne illness.
F 0867: The facility failed to sustain an effective QAPI plan, resulting in repeated deficiencies such as failure to ensure residents' nails were clipped.
F 0880: The facility failed to implement proper infection prevention practices during wound and perineal care, including inadequate hand hygiene, placing a resident at risk for infections.
Report Facts
Residents sampled: 19
Residents reviewed for wound care: 2
Residents sampled for nail clipping: 19
BIMS score: 13
BIMS score: 4
Date of admission: Aug 9, 2024
Date of admission: Oct 3, 2019
Date of physician order: Apr 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #3 | Confirmed call light was inaccessible to Resident #17. | |
| Licensed Practical Nurse (LPN) #2 | Confirmed call light placement was inappropriate for Resident #17. | |
| Director of Nursing (DON) | Acknowledged need for accessible call light device and commented on QAPI and grooming deficiencies. | |
| Nursing Home Administrator (NHA) | Acknowledged failure to follow QAPI plan and expectations for staff compliance. | |
| Registered Nurse (RN) #1, Wound Care Nurse | Observed and confirmed improper wound and peri care practices. | |
| Certified Nursing Assistant (CNA) #5 | Observed performing incomplete peri care and poor hand hygiene. | |
| Dietary Manager (DM) | Acknowledged responsibility for food safety and disposal of contaminated food. | |
| Cook | Acknowledged failure to properly close food thickener bag. | |
| Director of Food Services | Acknowledged food safety violations and expectations for dietary staff. | |
| Licensed Practical Nurse (LPN) #3, Infection Preventionist | Confirmed improper hand hygiene and infection risk during wound and peri care. |
Inspection Report — Jun 26, 2025
Routine
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living (ADLs) for residents, specifically focusing on grooming and personal hygiene services.
Findings
The facility failed to ensure that Resident #57, who was unable to perform ADLs independently, received necessary grooming and personal hygiene care, including facial hair trimming and toenail care. Interviews and observations confirmed the resident had long facial hair and toenails that were overdue for trimming.
Deficiencies (1)
F 0677: The facility failed to provide care and assistance for activities of daily living to Resident #57, resulting in inadequate grooming including untrimmed facial hair and toenails. The resident expressed a desire for assistance which was not provided despite staff responsibility.
Report Facts
Brief Interview Mental Score: 5
Residents Affected: 1
Inspection Report — Jun 23, 2025
Life Safety
Date: Jun 23, 2025
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 failed to provide the required half-hour fire resistance rating in the smoke barrier walls, with unsealed holes around data cables in all three smoke compartments affecting all 74 residents. The findings were acknowledged by the Administrator and Maintenance Supervisor during the exit interview.
Deficiencies (1)
K0372 - The facility failed to provide half-hour fire resistance rating in the smoke barrier walls due to unsealed holes around data cables in three smoke compartments, affecting all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — May 5, 2025
Follow-Up
Date: May 5, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/5/25 related to the complaint survey that was conducted 4/2/25 through 4/4/25.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 4/24/25.
Inspection Report — May 5, 2025
Follow-Up
Date: May 5, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/5/25 related to the complaint survey that was conducted 4/2/25 through 4/4/25.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 4/24/25.
Inspection Report — Apr 14, 2025
Complaint Investigation
Date: Apr 14, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28519 and CI MS #28522), both facility reported incidents related to resident-to-resident abuse.
Complaint Details
Two complaint investigations (CI MS #28519 and CI MS #28522) were conducted related to resident-to-resident abuse; both were facility reported incidents and no deficiencies were cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this investigation.
Report Facts
Complaint Investigations: 2
Inspection Report — Apr 14, 2025
Complaint Investigation
Date: Apr 14, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28519 and CI MS #28522) related to resident-to-resident abuse reported by the facility on 04/14/2025.
Complaint Details
Two complaint investigations (CI MS #28519 and CI MS #28522) were conducted related to resident-to-resident abuse. The facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited during this investigation.
Report Facts
Complaint Investigations conducted: 2
Inspection Report — Apr 4, 2025
Complaint Investigation
Date: Apr 4, 2025
Visit Reason
The inspection was conducted due to allegations of physical and verbal abuse by a Certified Nurse Aide (CNA #1) against residents, and failure to report and intervene promptly, as well as failure to submit a timely investigation report for another abuse allegation.
Complaint Details
The complaint investigation was triggered by allegations of physical abuse of Resident #1 and verbal abuse of Resident #2 by CNA #1, witnessed by other staff. The abuse was not reported until 10 days later. Additionally, the facility failed to submit a timely investigation report for verbal abuse allegations involving Resident #3. The allegations were substantiated based on staff statements and investigation.
Findings
The facility failed to protect residents from abuse, failed to intervene and report abuse immediately, and failed to submit a timely investigation report to the State Agency. Immediate Jeopardy was identified due to physical abuse of Resident #1 and verbal abuse of Resident #2 by CNA #1, with delayed reporting and intervention by staff. The facility implemented corrective actions and the Immediate Jeopardy was removed.
Deficiencies (4)
F600: The facility failed to protect residents from physical and verbal abuse by CNA #1 and failed to take immediate protective action or timely report the abuse, placing residents at risk of serious harm.
F607: The facility failed to implement its abuse policy, allowing abuse to occur without staff intervening or promptly reporting for two residents.
F609: The facility failed to report suspected abuse within two hours and failed to submit a completed investigation within five working days for three residents.
F0656: The facility failed to implement comprehensive care plan interventions for Resident #1, including failure to follow behavior management guidelines.
Report Facts
Days delay in reporting abuse: 10
Date of abuse incident: Mar 7, 2025
Date of report submission: Apr 4, 2025
BIMS score: 10
BIMS score: 3
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings for physical and verbal abuse of residents |
| CNA #2 | Certified Nurse Aide | Witnessed verbal abuse and failed to report immediately; received education on abuse policy |
| CNA #3 | Certified Nurse Aide | Witnessed physical abuse and failed to report immediately; assisted with care during abuse incident |
| Administrator | Facility Administrator | Received anonymous abuse allegations on 3/17/25, suspended and terminated CNA #1, involved in investigation |
| DON | Director of Nursing | Involved in investigation and confirmed failure to report abuse timely and follow care plans |
| LPN #1 | Licensed Practical Nurse | Assigned nurse during abuse incident, unaware of abuse at time |
| RN #2 | Registered Nurse | Confirmed failure to follow care plan for Resident #1 |
Inspection Report — Apr 4, 2025
Complaint Investigation
Date: Apr 4, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28311 and CI MS #28355) at the facility from 04/02/2025 to 04/04/2025 related to abuse allegations involving multiple residents.
Complaint Details
Two Complaint Investigations (CI MS #28311 and CI MS #28355) were conducted related to abuse allegations. CI MS #28355 involved verbal abuse by CNA #2 to Resident #3. CI MS #28311 involved physical and verbal abuse by CNA #1 to Residents #1 and #2. The abuse was substantiated and immediate jeopardy was identified and later removed.
Findings
The facility was found not in compliance due to failure to protect residents from physical and verbal abuse by a Certified Nurse Aide (CNA #1). The abuse was witnessed by other staff but not immediately reported, leaving residents vulnerable for ten days. The facility failed to implement timely protective actions and did not follow its abuse reporting policies.
Deficiencies (4)
F0600 - Free from Abuse and Neglect. The facility failed to ensure residents' right to be free from physical and verbal abuse when CNA #1 physically abused Resident #1 and verbally abused Resident #2 on 03/07/2025, and staff did not take immediate protective action or timely report the abuse, leaving residents vulnerable for ten days.
F0607 - Develop/Implement Abuse/Neglect Policies. The facility failed to implement its abuse policy by allowing abuse to occur without staff intervening or promptly reporting for two residents, and staff feared retaliation which delayed reporting.
F0609 - Reporting of Alleged Violations. The facility failed to report abuse within the required two-hour timeframe for Residents #1 and #2 and failed to submit a completed investigation within five working days for Resident #3.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement comprehensive care plan interventions for Resident #1 with combative behaviors, as staff did not follow the plan to allow the resident to calm down before providing care.
Report Facts
Deficiencies cited: 4
Inspection Report — Feb 26, 2025
Complaint Investigation
Date: Feb 26, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding insufficient nursing staff leading to resident neglect and failure to post required nurse staffing information.
Complaint Details
The complaint investigation found substantiated issues related to insufficient nursing staff on the night of February 23, 2025, causing a resident to remain soiled overnight, and failure to post required nurse staffing information on February 24 and 25, 2025.
Findings
The facility failed to provide adequate nursing staff during the overnight shift on February 23, 2025, resulting in a resident being left soiled all night. Additionally, the facility failed to post daily nurse staffing information for two of three survey days and did not include required elements in the Facility Assessment related to staffing by shift, recruitment, retention, and contingency planning.
Deficiencies (3)
F 0725: The facility failed to provide sufficient nursing staff on the night of February 23, 2025, resulting in a resident being left in urine all night due to only one CNA being on duty.
F 0732: The facility failed to post daily nurse staffing information in a visible and accessible location for two of three survey days, limiting transparency for residents and the public.
F 0838: The facility failed to conduct and document a facility-wide assessment that included staffing needs by shift, recruitment and retention plans, and contingency planning for non-emergency situations.
Report Facts
Residents sampled: 5
Licensed Practical Nurses (LPNs): 8
Nurse Aides: 16
Non-nursing administrative employees: 5
Social Services workers: 2
Contracted Dietitians: 1
Contracted dietary workers: 10
Respiratory workers: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Reported staffing shortage on February 23, 2025 overnight shift |
| Certified Nurse Aide #1 | CNA | Reported being the only CNA on duty during February 23, 2025 overnight shift |
| Director of Nursing | DON | Submitted facility staffing statement and acknowledged staffing posting failure |
| Administrator | Administrator | Acknowledged failure to post staffing information and lack of knowledge about staffing assessment requirements |
Inspection Report — Feb 26, 2025
Complaint Investigation
Date: Feb 26, 2025
Visit Reason
The State Agency conducted four Complaint Investigations (CI MS #28008, CI MS#28009, CI MS#28082, and CI MS #28083) from 02/24/25 through 02/26/25. Citations were issued related to CI MS#28009 and CI MS #28082.
Complaint Details
Four complaint investigations were conducted: CI MS #28008 (elopement, no citations), CI MS #28009 (staffing and feeding assessment, citations issued), CI MS #28082 (citations issued), and CI MS #28083 (neglect, no citations). Deficiencies cited related to CI MS #28009 and CI MS #28082.
Findings
The facility was found not in compliance with nursing staff sufficiency, nurse staffing information posting, and facility assessment requirements. Deficiencies were cited for insufficient nursing staff leading to a resident being left soiled overnight, failure to post nurse staffing information for two days, and an incomplete facility assessment lacking shift-specific staffing needs and contingency plans.
Deficiencies (3)
F0725 - Sufficient Nursing Staff. The facility failed to ensure sufficient nursing staff was available, resulting in a resident being left soiled all night due to only one CNA on duty during the overnight shift on 2/23/2025.
F0732 - Posted Nurse Staffing Information. The facility failed to post daily nurse staffing information in a visible and accessible location for two of three survey days, limiting transparency for residents and visitors.
F0838 - Facility Assessment. The facility assessment did not include shift-specific staffing needs, plans for recruitment and retention, or contingency planning for staffing shortages not requiring emergency plan activation.
Report Facts
Deficiencies cited: 3
Inspection Report — Dec 12, 2024
Complaint Investigation
Date: Dec 12, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26839, MS #26903, and MS #26986, at the facility from 12/10/24 through 12/12/24. MS #26839 was investigated related to resident not groomed, medication, water not offered, and equipment not maintained. MS #26903 was investigated for abuse and quality of care. MS #26989 was investigated for roaches in the facility, falls, and resident safety.
Complaint Details
Complaint Investigation (CI), MS #26839, MS #26903, and MS #26986 were conducted. The allegations included resident not groomed, medication issues, water not offered, equipment not maintained, abuse, quality of care, roaches, falls, and resident safety. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Dec 12, 2024
Complaint Investigation
Date: Dec 12, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26839, MS #26903, and MS #26986, at the facility from 12/10/24 through 12/12/24. The complaints involved resident grooming, medication, water not offered, equipment maintenance, abuse, quality of care, roaches, falls, and resident safety.
Complaint Details
Complaint Investigation MS #26839 involved resident grooming, medication, water not offered, and equipment maintenance; MS #26903 involved abuse and quality of care; MS #26989 involved roaches, falls, and resident safety. The facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaints investigated: 3
Inspection Report — Jun 13, 2024
Complaint Investigation
Date: Jun 13, 2024
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #24817, CI MS #24879, CI MS #24941, CI MS #24968, CI MS #25413, and CI MS #25417) at the facility from 6/11/24 through 6/13/24 related to nursing services, medication not given as prescribed, pressure sores, neglect, grooming, falls, feeding assistance, quality of care, and a fall resulting in a fracture.
Complaint Details
Six complaint investigations were conducted covering issues such as medication errors, neglect, pressure sores, grooming, falls, and quality of care. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint Investigations: 6
Inspection Report — Jun 13, 2024
Complaint Investigation
Date: Jun 13, 2024
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #24817, CI MS #24879, CI MS #24941, CI MS #24968, CI MS #25413, and CI MS #25417) at the facility from 6/11/24 through 6/13/24 related to nursing services, medication not given as prescribed, pressure sores, neglect, grooming, falls, feeding assistance, quality of care, and a fall injury resulting in a fracture.
Complaint Details
Six complaint investigations were conducted related to nursing services, medication errors, pressure sores, neglect, grooming, falls, feeding assistance, quality of care, and a fall injury resulting in a fracture. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid participation requirements and the Minimum Standards for Institutions for the Aged or Infirm, with no deficiencies cited.
Report Facts
Complaint Investigations conducted: 6
Inspection Report — Apr 10, 2024
Complaint Investigation
Date: Apr 10, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24214, at the facility on 4/10/24 related to pressure ulcers.
Complaint Details
Complaint Investigation MS #24214 was related to pressure ulcers. 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, state licensure requirement. There were no deficiencies cited.
Inspection Report — Apr 10, 2024
Complaint Investigation
Date: Apr 10, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #24214) related to pressure ulcers.
Complaint Details
CI MS #24214 was investigated related to pressure ulcers. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Mar 28, 2024
Complaint Investigation
Date: Mar 28, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #24249), a Facility Reported Incident (FRI), and CI MS #24241 at the facility from 3/26/24 through 3/28/24. CI MS #24241 was investigated related to facility staffing, call lights not answered, and Administration with no citations. CI MS #24249 was investigated related to residents' rights and deficiencies F578 and F656 were cited.
Complaint Details
CI MS #24249 was investigated related to residents' rights. The facility was found to be in compliance with no deficiencies cited for CI MS #24241. Deficiencies F578 and F656 were cited related to CI MS #24249.
Findings
The facility failed to honor a resident's right to refuse treatment when Resident #1, a hospice patient with a signed Do Not Resuscitate (DNR) Physician's Order, received CPR for 25 minutes against his wishes. The facility also failed to develop comprehensive care plan interventions regarding Advanced Directives for Resident #1. The Immediate Jeopardy identified was removed prior to the survey entrance based on corrective actions.
Deficiencies (2)
F0578 - The facility failed to honor a resident's right to refuse treatment when Resident #1, who had a signed DNR Physician's Order, received CPR for 25 minutes due to conflicting code status documentation and lack of communication among staff.
F0656 - The facility failed to develop and implement a comprehensive care plan for Resident #1 regarding Advanced Directives, resulting in CPR being performed against the resident's wishes.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 28, 2024
Complaint Investigation
Date: Mar 28, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to honor a resident's right to refuse treatment, specifically a Do Not Resuscitate (DNR) order, resulting in the resident receiving unwanted cardiopulmonary resuscitation (CPR).
Complaint Details
The complaint investigation was substantiated. The facility was found to have failed to honor the resident's DNR order, resulting in CPR being administered for 25 minutes contrary to the resident's wishes. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to honor Resident #1's DNR order due to conflicting documentation between the hard chart and electronic health record, causing CPR to be administered against the resident's wishes. The facility also failed to develop a comprehensive care plan reflecting the resident's advanced directives in a timely manner. Corrective actions were implemented, including audits, education, and monitoring, leading to removal of Immediate Jeopardy status.
Deficiencies (2)
F 0578: The facility failed to honor a resident's right to refuse treatment by administering CPR despite a signed DNR order due to conflicting code status documentation.
F 0656: The facility failed to develop a comprehensive care plan addressing advanced directives for a resident, resulting in CPR being performed against the resident's wishes.
Report Facts
Duration of CPR: 25
Number of residents reviewed: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse (LPN) #2 | Verified Resident #1 was Full Code in hard chart during investigation. | |
| License Practical Nurse (LPN) #3 | Verified Resident #1 was Full Code in hard chart and explained discrepancy leading to CPR initiation. | |
| Director of Nursing (DON) | Confirmed failure to review new DNR orders during clinical meeting and failure to develop comprehensive care plan. | |
| Social Services Director | Unaware of code status change at time of resident's return and did not review new orders during clinical meeting. | |
| Registered Nurse (RN) #3 | Delivered new hospice orders indicating DNR to facility staff. | |
| Executive Director | Reported incident to State Agency and participated in corrective action education. | |
| Regional Director of Clinical Services | Led audits, education, and monitoring related to code status and advanced directives. |
Inspection Report — Feb 19, 2024
Annual Inspection
Date: Feb 19, 2024
Visit Reason
On 02/19/24 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 01/19/24.
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. The SA is recommending that your facility be placed back in compliance effective 02/15/24.
Inspection Report — Feb 19, 2024
Date: Feb 19, 2024
Visit Reason
On 02/19/24 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 01/19/24. 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 02/15/24. No deficiencies were cited in this desk review.
Inspection Report — Jan 19, 2024
Routine
Date: Jan 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, notification of transfers, and staffing adequacy at The Oaks Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in honoring residents' bathing preferences, providing written transfer notifications, ensuring proper nail care, maintaining catheter bag placement to prevent infection, and staffing levels sufficient to meet resident needs. These deficiencies affected multiple residents and had the potential to impact all 77 residents.
Deficiencies (5)
F 0561: The facility failed to ensure residents' individual bathing preferences were followed for one of eighteen sampled residents. Resident #229 did not receive daily baths or showers as preferred, and no refusals were documented.
F 0623: The facility failed to provide written notification of transfer to a resident or resident representative for one of three closed records reviewed. Resident #74 was transferred without written notice.
F 0677: The facility failed to ensure a resident's nails were cleaned and clipped for one of eighteen sampled residents. Resident #69's nails were long, jagged, and discolored.
F 0690: The facility failed to maintain proper placement of a urinary catheter bag to prevent infection for one of three residents observed. Resident #228's catheter bag was observed touching the floor.
F 0725: The facility failed to provide sufficient nursing staff resulting in residents not receiving showers and nail care for five of seven sampled residents, potentially affecting all 77 residents.
Report Facts
Residents affected: 18
Residents affected: 3
Residents affected: 3
Residents affected: 5
Total residents: 77
BIMS score: 12
BIMS score: 12
BIMS score: 7
BIMS score: 15
BIMS score: 0
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided expectations on bathing schedules, refusal documentation, and staffing issues |
| Registered Nurse #2 | Registered Nurse | Confirmed bathing expectations and refusal documentation for Resident #229 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Verified Resident #69's nails were long and untrimmed |
| Wound Care Nurse #1 | Wound Care Nurse | Observed Resident #69's nails and confirmed they were untrimmed |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Stated catheter bag placement on floor was an infection control problem |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed catheter drainage bag should not be on the floor |
| Registered Nurse #2 | Registered Nurse | Confirmed catheter bag policy and infection control concerns |
| Administrator | Administrator | Acknowledged staffing shortages and efforts to hire staff |
| Business Office Manager | Business Office Manager | Clarified responsibilities regarding transfer notification |
| Social Services | Social Services Staff | Discussed transfer notification process |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed staffing shortages and shower provision issues |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Confirmed insufficient staff to provide showers |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Reported residents not getting showers daily due to staffing |
| Human Resource Director | Human Resource Director | Confirmed staffing shortages and communication with corporate office |
Inspection Report — Jan 19, 2024
Annual Inspection
Date: Jan 19, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 01/17/2024 through 01/19/2024. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and cited M225, M500, and M610.
Findings
The facility was found not in compliance with state licensure requirements due to insufficient nursing staff leading to residents not receiving showers and nail care, failure to follow residents' bathing preferences, and failure to ensure nail care was provided. Deficiencies were cited for inadequate staffing, residents' rights violations, and activities of daily living care.
Deficiencies (3)
M225 - The facility failed to provide sufficient nursing staff resulting in five of seven sampled residents not receiving showers and nail care, potentially affecting all 77 residents.
M500 - The facility failed to ensure residents' individual bathing preferences were followed for one of eighteen sampled residents, Resident #229, who did not receive daily baths or showers as requested.
M610 - The facility failed to ensure a resident's nails were cleaned and clipped for one of eighteen sampled residents, Resident #69, whose fingernails and toenails were long, jagged, discolored, and untrimmed for several weeks.
Report Facts
Deficiencies cited: 3
Inspection Report — Jan 19, 2024
Annual Inspection
Date: Jan 19, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 01/17/2024 through 01/19/2024. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F561, F623, F677, F690, and F725.
Findings
The facility was found not in compliance with requirements related to resident self-determination, transfer/discharge notification, ADL care, catheter care, and sufficient nursing staff. Deficiencies were identified in bathing preferences, written transfer notices, nail care, catheter bag placement, and staffing levels impacting resident care.
Deficiencies (5)
F0561 - The facility failed to ensure residents' individual bathing preferences were followed for one resident, resulting in missed showers despite no refusals documented.
F0623 - The facility failed to provide written notification of transfer to a resident and their representative for one resident transferred to an inpatient psychiatric facility.
F0677 - The facility failed to ensure a resident's nails were cleaned and clipped, with nails observed long, jagged, and discolored.
F0690 - The facility failed to maintain proper placement of a urinary catheter bag, which was observed touching the floor, increasing infection risk.
F0725 - The facility failed to provide sufficient nursing staff, resulting in residents not receiving showers and nail care, and staffing shortages impacting resident care.
Report Facts
Deficiencies cited: 5
Inspection Report — Jan 17, 2024
Life Safety
Date: Jan 17, 2024
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 was found to meet 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 — Nov 28, 2023
Complaint Investigation
Date: Nov 28, 2023
Visit Reason
The inspection was conducted following a complaint of verbal abuse by a housekeeper toward a resident at The Oaks Rehabilitation and Healthcare Center.
Complaint Details
The complaint was substantiated. The housekeeper verbally abused Resident #1 on 10/23/23 by entering his room without permission and arguing with him. The facility investigated promptly, placed the employee on leave, and provided abuse training. The deficiency was corrected prior to the State Agency's entrance on 11/27/23.
Findings
The facility failed to protect Resident #1 from verbal abuse by a housekeeper who entered the resident's room without permission and argued with him. The housekeeper was placed on leave and subsequently left employment. The facility conducted an immediate investigation and provided in-service training on abuse.
Deficiencies (1)
F 0600: The facility failed to protect a resident from verbal abuse by a housekeeper who entered the resident's room without permission and engaged in a verbal altercation. The housekeeper ignored the resident's requests to leave and used inappropriate language.
Report Facts
Residents sampled: 6
Residents affected: 1
Brief Interview for Mental Status (BIMS) score: 14
Date of incident: Oct 23, 2023
Date of investigation: Oct 26, 2023
Date of survey completion: Nov 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Contract employee who verbally abused Resident #1 and was placed on leave before leaving employment | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding the incident and facility response | |
| Certified Nurse Aide (CNA) #1 | Witnessed the incident and provided a statement | |
| Housekeeper #2 | Reported awareness of the verbal abuse incident and employee resignation | |
| Director of Nursing (DON) | Provided abuse and misappropriation in-service training starting 10/23/23 |
Inspection Report — Nov 28, 2023
Complaint Investigation
Date: Nov 28, 2023
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #23135 and CI MS #23107) at the facility from 11/27/23 through 11/28/23. MS #23107 was investigated related to staffing, missing items, resident assessment, and Administration with no deficiencies cited. MS #23135 was a Facility Reported Incident related to employee to resident verbal abuse and cited F600.
Complaint Details
CI MS #23135 was a Facility Reported Incident related to employee to resident verbal abuse. The deficiency was substantiated and cited as F600. The facility implemented corrective actions on 10/23/23 and the deficiency was determined to be Past Non-Compliance.
Findings
The facility was found in compliance with the complaint CI MS #23107. For CI MS #23135, the facility failed to protect a resident from verbal abuse by a housekeeper who entered a resident's room without permission and argued with the resident, using profanity. The deficiency was determined to be Past Non-Compliance and corrected prior to the survey.
Deficiencies (1)
F0600 - The facility failed to protect a resident from verbal abuse by a housekeeper who entered the resident's room without permission, argued with the resident, and used profanity. The facility investigated and took corrective actions prior to the survey.
Report Facts
Complaints investigated: 2
Deficiencies cited: 1
Facility licensed beds: 82
Inspection Report — Sep 12, 2023
Complaint Investigation
Date: Sep 12, 2023
Visit Reason
On 09/12/23 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 08/16/23. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 08/16/23; the facility was found in compliance after corrective measures were confirmed.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 09/08/23. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 16, 2023
Complaint Investigation
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to allegations of resident on resident abuse at The Oaks Rehabilitation and Healthcare Center. The investigation focused on the facility's failure to report and thoroughly investigate the abuse incident involving two residents.
Complaint Details
The complaint involved an incident on or around 8/5/23 or 8/6/23 where Resident #2 hit Resident #1. The facility staff failed to report the incident to the State Agency and did not complete a thorough investigation. Interviews with multiple staff confirmed the failure to report and incomplete investigation.
Findings
The facility failed to timely report suspected resident on resident abuse to the State Agency and did not conduct a thorough investigation of the abuse allegations. Staff were aware of the incident but did not follow policy requirements for reporting and investigation.
Deficiencies (2)
F 0609: The facility failed to timely report suspected resident on resident abuse to the State Agency for one of three abuse allegations reviewed.
F 0610: The facility failed to thoroughly investigate resident on resident abuse for one of three abuse allegations reviewed.
Report Facts
Residents affected: 3
Dates of abuse training: Facility provided abuse training on 8/7/23, 6/30/23, and 2/12/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported bruise on Resident #1 and informed DON |
| Director of Nursing | DON | Responsible for reporting abuse and investigation; failed to report to State Agency |
| RN #1 | Registered Nurse / Assistant Director of Nursing | Directed to investigate allegations but did not complete investigation |
| LPN #2 | Licensed Practical Nurse | Witnessed altercation and reported to LPN #3 |
| LPN #3 | Licensed Practical Nurse | Received report of altercation, notified DON, completed SBAR report |
| Administrator | Facility Administrator | Expected staff to follow abuse reporting and investigation policies |
Inspection Report — Jun 22, 2023
Complaint Investigation
Date: Jun 22, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #20914 and MS #21298, at the facility from 6/21/23 through 6/22/23. MS #20914 related to offensive odors and residents denied visitation. MS #21298 related to falls, residents left wet, and quality of care.
Complaint Details
Complaint Investigations MS #20914 and MS #21298 were conducted. MS #20914 concerned offensive odors and residents denied visitation. MS #21298 concerned falls, residents left wet, and quality of care. No deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Jun 22, 2023
Complaint Investigation
Date: Jun 22, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #20914 and MS #21298, at the facility from 6/21/23 through 6/22/23. The investigations related to offensive odors, resident denied visitation, falls, residents left wet, and quality of care.
Complaint Details
Complaint numbers MS #20914 and MS #21298 were investigated. Allegations included offensive odors, resident denied visitation, falls, residents left wet, and quality of care. The complaints were not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited during the complaint investigations.
Inspection Report — Aug 26, 2022
Annual Inspection
Date: Aug 26, 2022
Visit Reason
On 08/26/22 the State Agency conducted a desk review of the information provided related to the annual survey completed on 06/23/22. 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 08/04/22. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 28, 2022
Complaint Investigation
Date: Jul 28, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19393 at the facility on 7/28/22. The SA did not substantiate the complaint for verbal abuse.
Complaint Details
Complaint MS #19393 alleged verbal abuse; the complaint was not substantiated.
Findings
The facility remains out of compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on the annual survey completed on June 23, 2022.
Inspection Report — Jul 28, 2022
Complaint Investigation
Date: Jul 28, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19393 at the facility on 7/28/22 regarding verbal abuse allegations.
Complaint Details
CI MS#19393 - Allegation of verbal abuse was investigated and not substantiated; no deficiencies cited.
Findings
The complaint for verbal abuse was not substantiated and no deficiencies were cited as a result of this investigation.
Report Facts
Deficiencies cited: 0
Inspection Report — Jun 23, 2022
Complaint Investigation
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to resolve a resident grievance, verbal abuse by staff, incomplete care plans for pressure ulcers, failure to transcribe physician wound care orders, and improper food storage.
Complaint Details
The complaint investigation included substantiated findings that the facility failed to resolve a grievance about a missing guitar, failed to protect residents from verbal abuse, failed to develop and revise care plans for pressure ulcers, failed to transcribe wound care orders, and failed to properly store expired food.
Findings
The facility failed to promptly resolve a grievance about a missing guitar for one resident, failed to protect six residents from verbal abuse by a staff member, failed to develop and revise care plans for pressure ulcers for one resident, failed to transcribe wound care physician orders for one resident, and failed to properly store expired orange juice in the medication room.
Deficiencies (6)
F 0585: The facility failed to make prompt efforts to resolve a grievance for one resident regarding a missing guitar that was not documented or investigated properly.
F 0600: The facility failed to protect six residents from verbal abuse by a Certified Nursing Assistant who used rude and belittling language.
F 0656: The facility failed to initiate a care plan with goals and interventions for one resident with new pressure ulcers to the left gluteal fold.
F 0657: The facility failed to revise a care plan when treatment was changed and wounds were resolved for one resident with multiple foot ulcers.
F 0658: The facility failed to ensure physician wound care orders were transcribed into the medical record for one resident with pressure ulcers and venous wounds.
F 0812: The facility failed to store food in accordance with professional standards by keeping orange juice past the discard date in the medication room.
Report Facts
Residents sampled: 18
Residents affected: 1
Residents affected: 6
Residents affected: 1
Number of orange juice containers expired: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding missing guitar grievance and grievance log | |
| Business Manager | Interviewed regarding missing guitar grievance and prior investigation | |
| Interim Administrator | Interviewed regarding grievance process and verbal abuse investigation | |
| CNA #3 | Certified Nursing Assistant | Named in multiple verbal abuse allegations |
| Interim Director of Nursing | Interviewed regarding care plan and wound care order transcription failures | |
| Licensed Practical Nurse #4 | Interviewed regarding care plan updates and wound care | |
| Hospice RN #1 | Interviewed regarding wound care and orders for Resident #66 | |
| Licensed Practical Nurse #3 | Interviewed regarding expired orange juice in medication room | |
| Licensed Practical Nurse #1 | Interviewed regarding responsibility for medication room contents |
Inspection Report — Jun 21, 2022
Routine
Date: Jun 21, 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.
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 — Jun 21, 2022
Life Safety
Date: Jun 21, 2022
Visit Reason
Survey conducted on 06/21/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Jun 8, 2022
Complaint Investigation
Date: Jun 8, 2022
Visit Reason
On 06/08/22 the State Agency conducted a desk review of information related to the complaint survey conducted on 04/21/22. The facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint investigation conducted on 04/21/22; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility in compliance and recommended the facility be placed back in compliance effective 06/01/22.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 21, 2022
Complaint Investigation
Date: Apr 21, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI) for MS #18715, MS #18709, MS #18708, MS #18677, MS #18390 and MS #18282 at the facility from 4/18/22 through 4/21/22. The SA substantiated MS #18709 and MS #18715 because the facility failed to provide incontinence care in a manner to prevent infection.
Complaint Details
Complaint Investigation (CI) for MS #18715, MS #18709, MS #18708, MS #18677, MS #18390 and MS #18282. MS #18709 and MS #18715 were substantiated for failure to provide incontinence care to prevent infection. MS #18708 and MS #18677 were not substantiated for neglect, falls, and resident oversedation. MS #18390 and MS #18282 were not substantiated for insufficient staffing.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failures in incontinence care and infection control practices. Deficiencies were cited for improper application of medicated creams by unlicensed staff, inadequate incontinence care technique risking infection, and failure to follow infection prevention protocols including glove use.
Deficiencies (3)
F0658 - Services provided did not meet professional standards as unlicensed staff applied medicated cream containing zinc oxide to residents, contrary to facility policy.
F0690 - The facility failed to provide incontinent care using proper technique for three residents, risking infection due to improper wiping methods and failure to dispose of wipes appropriately.
F0880 - Infection prevention and control program was inadequate as staff failed to change contaminated gloves between care tasks, potentially spreading infection to residents.
Report Facts
Deficiencies cited: 3
Complaint count: 6
Inspection Report — Jun 14, 2021
Complaint Investigation
Date: Jun 14, 2021
Visit Reason
The State Agency conducted a Complaint Investigation, CI # 17776 from 5/4/2021 through 5/7/2021 related to an elopement. An onsite revisit was completed on 6/14/21 to verify compliance.
Complaint Details
Complaint Investigation CI # 17776 related to an elopement was substantiated. The facility was found in substantial compliance after the revisit.
Findings
The facility was found in substantial compliance with Medicare and Medicaid participation requirements effective 6/03/21 following the complaint investigation and revisit.
Report Facts
Complaint Investigations: 1
Inspection Report — May 7, 2021
Complaint Investigation
Date: May 7, 2021
Visit Reason
The State Agency (SA) conducted a Complaint Investigation, CI # 17776 from 5/4/2021 through 5/7/2021 and substantiated CI #17776 related to an elopement when the facility failed to provide adequate staff supervision to prevent Resident #1's elopement from the facility on 4/25/21. The SA also investigated CI #16978 regarding urinary tract infections, pressure sores and medication issues and CI#16794 related to notification transfer/discharge which were not substantiated.
Complaint Details
CI #17776 was substantiated related to an elopement when the facility failed to provide adequate staff supervision to prevent Resident #1's elopement on 4/25/21. The facility was not aware of Resident #1's absence until an off-duty staff saw the resident walking on a busy highway. The facility failed to report the incident timely to the State Survey Agency. Other complaints CI #16978 and CI #16794 were not substantiated.
Findings
The facility was found not in compliance due to failure to provide adequate supervision to prevent Resident #1's elopement on 4/25/21 and failure to report the incident to the State Survey Agency in a timely manner. Resident #1 left the facility unnoticed and unsupervised, was found walking on a busy highway, and was discharged from the facility on the same day. The facility implemented corrective actions and the Immediate Jeopardy was removed on 5/6/2021.
Deficiencies (2)
F0609 - Reporting of Alleged Violations. The facility failed to report an elopement incident involving Resident #1 to the State Survey Agency until May 5, 2021, despite the resident leaving the facility unsupervised on 4/25/21 and being found walking on a busy highway.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision and maintain secure environment to prevent Resident #1, who was at risk for elopement, from leaving the facility unnoticed through a window on 4/25/21. The resident was found walking on a busy four-lane highway with an abrasion and was discharged from the facility the same day.
Report Facts
Deficiencies cited: 2
Inspection Report — Sep 25, 2020
Routine
Date: Sep 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on September 25, 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 — Sep 25, 2020
Routine
Date: Sep 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on September 23, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 29, 2020
Routine
Date: Jun 29, 2020
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period as required by regulation.
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 between 06/15/2020 and 06/28/2020.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 22, 2020
Routine
Date: Jun 22, 2020
Visit Reason
The survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the National Healthcare Safety Network (NHSN).
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 — Jun 15, 2020
Routine
Date: Jun 15, 2020
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period as required by regulation.
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 between 06/01/2020 and 06/14/2020 as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — May 22, 2020
Routine
Date: May 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/22/20. 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 — May 23, 2019
Annual Inspection
Date: May 23, 2019
Visit Reason
The State Agency (SA) conducted an annual survey from 05/20/19 through 05/23/19. During the survey the SA determined the facility was not in compliance with the Medicare and Medicaid Requirements of participation.
Findings
The survey identified deficiencies in resident rights, reasonable accommodations, resident and family group response, privacy, comprehensive assessments, care planning, staffing, and food safety. The facility failed to ensure residents wore appropriate footwear, provide showers during shower room closure, follow up on resident council grievances, maintain resident privacy, complete timely MDS assessments, revise care plans, maintain sufficient staffing, and ensure food safety with dated milk.
Deficiencies (11)
F0550 - Resident Rights/Exercise of Rights. The facility failed to protect and promote a resident's dignity when Resident #52 was taken to the dining room without footwear.
F0558 - Reasonable Accommodations Needs/Preferences. The facility failed to provide showers for over a month due to shower room closure, affecting 11 residents who preferred showers.
F0565 - Resident/Family Group and Response. The facility failed to follow up on a grievance from the Resident Council regarding a canceled activity outing that was not rescheduled.
F0583 - Personal Privacy/Confidentiality of Records. The facility failed to provide privacy for Residents #228 and #41 when their bathroom door would not close completely.
F0637 - Comprehensive Assessment After Significant Change. The facility failed to initiate a significant change MDS for Resident #36 after feeding tube insertion and significant weight loss.
F0641 - Accuracy of Assessments. The facility failed to accurately code Resident #70's MDS to reflect a left heel wound.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop an individualized dementia care plan for Resident #56.
F0657 - Care Plan Timing and Revision. The facility failed to revise care plans timely for Residents #36 and #56 to reflect weight loss, NPO status, and anticoagulant use.
F0725 - Sufficient Nursing Staff. The facility failed to provide sufficient nursing staff on a 24-hour basis for 10 of 14 days reviewed, affecting all residents.
F0812 - Food Procurement/Store/Prepare/Serve-Sanitary. The facility failed to ensure milk cartons had use by or expiration dates, resulting in undated milk being stored and potentially served.
E0391 - EP Testing Requirements. The facility failed to conduct required annual emergency preparedness exercises including tabletop and community-based exercises.
Report Facts
Deficiencies cited: 11
Days with insufficient staffing: 10
Milk cartons undated: 150
Total licensed beds: 82
10 CMS Surveys
CMS Survey — Aug 16, 2023
Aug 16, 2023
CMS Survey — Nov 28, 2023
Nov 28, 2023
CMS Survey — Mar 28, 2024
Mar 28, 2024
CMS Survey — Feb 26, 2025
Feb 26, 2025
CMS Survey — Apr 4, 2025
Apr 4, 2025
CMS Survey — Jun 26, 2025
Jun 26, 2025
CMS Survey — Nov 19, 2025
Nov 19, 2025
CMS Survey — Jun 23, 2022
Jun 23, 2022
CMS Survey — Jan 19, 2024
Jan 19, 2024
CMS Survey — Jun 26, 2025
Jun 26, 2025
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