Deficiencies (last 7 years)
Deficiencies (over 7 years)
25.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
574% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
85% occupied
Based on a October 2025 inspection.
Occupancy over time
Inspection Report
Follow-Up
Census: 153
Capacity: 180
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 10/1/25 related to an annual and complaint survey that was conducted from 8/18/25 through 8/21/25.
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 9/22/25.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 10/1/25 related to an annual and complaint survey conducted from 8/18/25 through 8/21/25.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 9/22/25.
Inspection Report
Complaint Investigation
Census: 153
Capacity: 180
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #2600540) related to environment, verbal abuse, food/dining, medication, staffing, and grievances at the facility.
Complaint Details
Complaint Investigation (CI MS #2600540) was related to environment, verbal abuse, food/dining, medication, staffing, and grievances. No deficiencies were cited during this investigation.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements with no deficiencies cited. However, the facility remains out of compliance due to deficiencies cited in a prior survey on 2025-08-21.
Report Facts
Licensed beds: 180
Census: 153
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2600540, related to environment, verbal abuse, food/dining, medication, staffing, and grievances at the facility.
Complaint Details
Complaint Investigation MS #2600540 was related to environment, verbal abuse, food/dining, medication, staffing, and grievances. No deficiencies were cited during this investigation.
Findings
During the survey, the facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, with no deficiencies cited. However, the facility remains out of compliance due to deficiencies cited on the 8/21/2025 survey.
Report Facts
Complaint Investigation Number: 2600540
Previous survey date: Aug 21, 2025
Inspection Report
Life Safety
Census: 148
Deficiencies: 2
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) and emergency preparedness requirements.
Findings
The facility failed to provide corridor doors in accordance with NFPA 101 section 19.3.6.3, affecting one of five smoke compartments and 18 of 148 residents. Specific door hardware issues were observed on Resident Room #410 and #412 doors. Emergency preparedness requirements were met with no deficiencies cited.
Deficiencies (2)
Corridor doors did not close to a latching position resisting the passage of smoke in Resident Room #410 due to misaligned door striker.
Corridor door in Resident Room #412 was missing the door striker piece of hardware, preventing the door from closing to a latching position.
Report Facts
Residents affected: 18
Smoke compartments affected: 1
Total residents present: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged the door deficiencies during the exit interview | |
| Maintenance Supervisor | Verified the door deficiencies during the exit interview |
Inspection Report
Life Safety
Census: 148
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) and emergency preparedness requirements.
Findings
The facility failed to provide corridor doors in accordance with NFPA 101 section 19.3.6.3, affecting one of five smoke compartments and 18 of 148 residents. Specific door hardware issues were observed in Resident Rooms #410 and #412. Emergency preparedness requirements were met with no deficiencies cited.
Deficiencies (1)
Corridor doors did not close to a latching position resisting the passage of smoke in Resident Rooms #410 and #412.
Report Facts
Residents affected: 18
Smoke compartments affected: 1
Total residents present: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged the door deficiencies during the exit interview | |
| Maintenance Supervisor | Verified the door deficiencies during the exit interview |
Inspection Report
Annual Inspection
Capacity: 180
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 8/18/2025 through 8/21/2025, including investigations related to narcotic diversion, equipment and nursing services, and resident sedation.
Complaint Details
Complaint investigations included a facility reported incident related to possible narcotic diversion, a complaint related to equipment and nursing services, and an investigation of a resident being over sedated. No citations were issued related to these complaints.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, with deficiencies cited in staffing, residents' rights, activities of daily living, safe food handling, and infection control. No citations were issued related to the complaint investigations.
Deficiencies (5)
Failed to meet the minimum 2.8 hours of direct nursing care per resident per 24 hours for four of 58 days reviewed in February and March 2025.
Failed to ensure residents’ rights by not maintaining privacy during incontinent care for Resident #26 and failing to resolve a grievance in a timely manner for Resident #59.
Failed to provide adequate Activities of Daily Living care, as Resident #74 was not properly cleaned after episodes of incontinence.
Failed to ensure food items were properly stored, dated, and labeled in the dry goods room, freezer, and cooler.
Failed to prevent possible spread of infection by not following proper hand hygiene for Resident #26 and placing soiled linen directly on the floor for two of four days of survey.
Report Facts
Deficiency days below staffing requirement: 4
Resident census for staffing requirement: 180
Grievance resolution timeframe: 5
Delay in tablet replacement: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed providing incontinent care with door open and failing to maintain privacy and proper hand hygiene. |
| CNA #5 | Certified Nursing Assistant | Confirmed staffing shortages and admitted placing soiled linen on the floor. |
| Director of Nursing | Director of Nursing | Provided statements regarding staffing expectations, dignity, and infection control deficiencies. |
| Administrator | Facility Administrator | Confirmed staffing requirements, grievance delays, and expectations for policy compliance. |
| Licensed Practical Nurse #1 | Staff Development Nurse | Confirmed staffing calculations and shortages. |
| Registered Nurse #1 | Nurse Scheduler | Confirmed staffing shortages and calculations. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Reported inadequate cleaning of Resident #74. |
| Licensed Social Worker | Licensed Social Worker | Observed dignity concerns and provided information on grievance and resident issues. |
| Dietary Manager | Dietary Manager | Acknowledged food storage deficiencies. |
Inspection Report
Annual Inspection
Census: 148
Capacity: 180
Deficiencies: 8
Date: Aug 21, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 08/18/2025 through 08/21/2025, including investigations related to narcotic diversion, equipment and nursing services, and resident sedation.
Complaint Details
Complaint investigations included narcotic diversion, equipment and nursing services, and resident over sedation. No citations were issued for narcotic diversion or equipment/nursing services complaints. Citation was issued for resident over sedation (F605).
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with citations issued for resident rights, grievance resolution, chemical restraint use, medication management, care plan standards, ADL care, food safety, quality assurance, and infection control.
Deficiencies (8)
Failed to respect a resident’s privacy during incontinent care with door left open exposing resident's buttocks and genital area.
Failed to resolve a resident grievance in a timely manner; replacement of broken tablet delayed nearly three months.
Failed to ensure antipsychotic medications were prescribed with appropriate, clinically documented diagnoses for one resident.
Failed to ensure physician orders were followed for obtaining Hemoglobin A1C lab test as ordered.
Failed to provide adequate ADL care to ensure a resident was kept clean after episodes of incontinence.
Failed to ensure food items were properly stored, dated, and labeled in the dry goods room, freezer, and cooler.
Failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to ADL care and food storage.
Failed to prevent possible spread of infection by not following proper hand hygiene and placing soiled linen directly on the floor.
Report Facts
Census: 148
Total Capacity: 180
Grievance delay: 3
Residents reviewed for unnecessary medications: 6
Residents sampled for ADL care: 29
Kitchen observations: 2
Months of audits conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed providing incontinent care without maintaining privacy and failing to perform hand hygiene after care |
| Director of Nursing | Director of Nursing (DON) | Confirmed privacy and infection control failures and explained medication order processes |
| Licensed Social Worker | Licensed Social Worker (LSW) | Observed care and confirmed infection control and dignity concerns |
| Administrator | Facility Administrator | Provided statements on expectations for staff compliance and QAPI activities |
| CNA #3 | Certified Nurse Aide | Reported inadequate cleaning of Resident #74 during incontinence care |
| CNA #5 | Certified Nurse Aide | Admitted placing soiled linen on floor instead of bagging immediately |
| RN #1 | Registered Nurse | Confirmed staff infection control training and reported on soiled linen incident |
| Dietary Manager | Dietary Manager | Acknowledged food storage deficiencies and confirmed policy requirements |
| Pharmacist | Pharmacist | Explained medication review process and diagnosis documentation |
Inspection Report
Annual Inspection
Census: 148
Capacity: 180
Deficiencies: 8
Date: Aug 21, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 8/18/2025 through 8/21/2025, including investigations related to narcotic diversion, equipment and nursing services, and resident sedation concerns.
Complaint Details
Complaint investigations included narcotic diversion, equipment and nursing services, and a resident being over sedated. Only the over sedation complaint resulted in a citation (F605).
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies cited in resident rights, grievance resolution, chemical restraint use, medication management, ADL care, food safety, quality assurance, and infection control.
Deficiencies (8)
Failed to respect a resident’s privacy during incontinent care with the door open exposing the resident's buttocks and genital area.
Failed to resolve a resident grievance in a timely manner, delaying replacement of a broken tablet for nearly three months.
Failed to ensure antipsychotic medications were prescribed with appropriate, clinically documented diagnoses for one resident.
Failed to ensure physician orders were followed for obtaining a Hemoglobin A1C test as ordered for one resident.
Failed to provide adequate ADL care to ensure a resident was kept clean after episodes of incontinence, requiring multiple wipes to remove residue.
Failed to ensure food items were properly stored, dated, and labeled in the dry goods room, freezer, and cooler.
Failed to sustain corrective actions through QAPI to prevent recurrence of deficiencies related to ADL care and food storage.
Failed to prevent possible spread of infection by not following proper hand hygiene and placing soiled linen on the floor.
Report Facts
Census: 148
Total Capacity: 180
Deficiencies cited: 8
Grievance delay: 3
BIMS score: 8
BIMS score: 15
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in privacy and infection control deficiencies for failing to close door during care and not performing hand hygiene. |
| Director of Nursing | Director of Nursing | Confirmed expectations for privacy, hygiene, and infection control; acknowledged deficiencies. |
| Administrator | Administrator | Provided statements on expectations for dignity, infection control, food storage, and QAPI activities. |
| Licensed Social Worker | Licensed Social Worker | Observed privacy violation and confirmed infection control issue. |
| CNA #3 | Certified Nurse Aide | Observed inadequate cleaning of Resident #74. |
| CNA #5 | Certified Nurse Aide | Admitted placing soiled linen on the floor. |
| RN #1 | Registered Nurse | Confirmed staff in-service on infection control and reported about soiled linen incident. |
| Dietary Manager | Dietary Manager | Acknowledged food storage deficiencies and provided in-service education. |
| Pharmacist | Pharmacist | Explained medication review process and diagnoses documentation. |
Inspection Report
Annual Inspection
Capacity: 180
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations at the facility from 8/18/2025 through 8/21/2025, including investigations related to narcotic diversion, equipment and nursing services, and resident sedation.
Complaint Details
Complaint investigations included a facility reported incident related to possible narcotic diversion, a complaint related to equipment and nursing services, and an investigation of a resident being over sedated. No citations were issued related to these complaints.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, with deficiencies cited in nursing staffing, residents' rights, activities of daily living, safe food handling, and infection control.
Deficiencies (5)
Failed to meet the requirement of 2.8 hours of direct nursing care per resident per 24 hours on four days in February and March 2025.
Failed to ensure residents' rights by not maintaining privacy during incontinent care for Resident #26 and failing to resolve a grievance in a timely manner for Resident #59.
Failed to provide adequate Activities of Daily Living care, as Resident #74 was not properly cleaned after incontinence episodes.
Failed to ensure proper food storage, dating, and labeling in the dry goods room, freezer, and cooler during kitchen observations.
Failed to maintain effective infection control practices, including failure to follow proper hand hygiene and placing soiled linen on the floor.
Report Facts
Deficiency days below staffing requirement: 4
Resident sample size: 29
Facility capacity: 180
BIMS score: 8
BIMS score: 15
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed providing incontinent care with door open and failing to follow proper hand hygiene. |
| CNA #5 | Certified Nursing Assistant | Confirmed staffing shortages and admitted placing soiled linen on the floor. |
| Director of Nursing | Director of Nursing | Provided statements on staffing expectations, dignity policies, and infection control. |
| Administrator | Facility Administrator | Confirmed staffing goals, food storage expectations, and infection control policy adherence. |
| Licensed Social Worker | Licensed Social Worker | Observed dignity violation and provided information on grievance and resident care. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported inadequate cleaning of Resident #74 during incontinence care. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to investigate concerns regarding the use of unnecessary psychotropic medications or medications that may restrain a resident's ability to function.
Complaint Details
The visit was complaint-related, focusing on the use of unnecessary psychotropic medications. The report indicates that the deficiency was substantiated based on staff interviews, record reviews, and policy review.
Findings
The facility failed to ensure that antipsychotic medications were prescribed only for residents with appropriate, clinically documented diagnoses. Specifically, one of six residents reviewed was prescribed antipsychotic medications without adequate supporting diagnoses documented in the medical record.
Deficiencies (1)
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Report Facts
Residents reviewed for unnecessary medications: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| pharmacist | Interviewed regarding monthly medication reviews and diagnosis evaluations | |
| Director of Nursing (DON) | Interviewed regarding medication order process and diagnosis verification |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and facility policies.
Findings
The facility was found deficient in multiple areas including failure to respect resident privacy during care, untimely grievance resolution, failure to follow physician orders for lab tests, inadequate activities of daily living (ADL) care, improper food storage, failure to sustain quality assurance improvements, and lapses in infection prevention and control practices.
Deficiencies (7)
Failed to respect a resident's privacy during incontinent care with the resident's door open and body exposed.
Failed to resolve a grievance in a timely manner regarding replacement of a broken tablet, delayed nearly three months.
Failed to ensure physician orders were followed for obtaining Hemoglobin A1C lab test as ordered.
Failed to provide adequate ADL care to ensure a resident was kept clean after incontinence episodes.
Failed to ensure food items were properly stored, dated, and labeled in dry goods room, freezer, and cooler.
Failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to ADL care and food storage.
Failed to prevent possible spread of infection by not following proper hand hygiene and placing soiled linen on the floor.
Report Facts
Residents sampled: 29
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Kitchen observations: 2
Residents affected: 2
BIMS score: 8
BIMS score: 15
BIMS score: 13
BIMS score: 10
Tablet replacement delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in privacy and infection control deficiencies for Resident #26 |
| Licensed Social Worker (LSW) | Observed privacy and infection control issues with RN #2 | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding privacy, lab order, infection control, and ADL care deficiencies |
| Administrator | Facility Administrator | Interviewed regarding grievance delay, food storage, QAPI, and infection control expectations |
| RN #1 | Registered Nurse | Responsible for monitoring labs and infection control procedures |
| Certified Nurse Aide (CNA) #3 | Certified Nurse Aide | Observed providing inadequate ADL care to Resident #74 |
| Certified Nurse Aide (CNA) #4 | Certified Nurse Aide | Interviewed about Resident #74 care |
| Certified Nurse Aide (CNA) #5 | Certified Nurse Aide | Observed placing soiled linen on floor |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding food storage deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
The State Agency conducted complaint investigations related to weight loss and pressure sores (MS #28930) and falls, resident not assessed, and transfers (MS #28978) at the facility on 2025-06-09.
Complaint Details
Complaint investigations MS #28930 and MS #28978 were conducted related to weight loss, pressure sores, falls, resident not assessed, and transfers. No deficiencies were 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 requirements. There were no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 148
Capacity: 180
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
The State Agency conducted complaint investigations related to weight loss and pressure sores (MS #28930) and falls, resident not assessed, and transfers (MS #28978).
Complaint Details
Complaint investigations MS #28930 and MS #28978 were conducted related to weight loss, pressure sores, falls, resident not assessed, and transfers. The facility was found compliant with no deficiencies.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigations.
Report Facts
Licensed beds: 180
Census: 148
Inspection Report
Complaint Investigation
Census: 147
Capacity: 180
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The State Agency conducted a complaint investigation from 2025-04-02 through 2025-04-03 related to an elopement incident involving Resident #1 who exited the facility unnoticed on 2025-03-23.
Complaint Details
The complaint investigation was triggered by an elopement incident involving Resident #1 on 2025-03-23. The facility was found to have Immediate Jeopardy and Substandard Quality of Care beginning on that date. The Immediate Jeopardy was removed on 2025-03-24 after corrective actions were implemented. The resident was found outside the facility approximately 130 feet from his room, wearing shorts with no shirt or shoes. The resident was assessed with no injuries or psychosocial harm.
Findings
The facility failed to provide adequate supervision and environmental safety to prevent Resident #1, a cognitively impaired resident, from removing a window screen and exiting the facility unnoticed. Immediate Jeopardy and Substandard Quality of Care were identified but were corrected by 2025-03-24 prior to the survey. Corrective actions included securing windows with L-brackets, staff in-services, elopement drills, and increased observation of residents.
Deficiencies (1)
Failure to provide adequate supervision and ensure environmental safety to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Licensed capacity: 180
Resident census: 147
Distance resident walked: 130
BIMS score: 8
Residents at risk for wandering/elopement: 58
Total residents assessed for wandering/elopement risk: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Provided care and assessment of Resident #1 on 3/23/25 and confirmed no prior elopement behaviors |
| CNA #1 | Certified Nurse Aide | Observed Resident #1 attempting to enter another resident's room and redirected him; assisted in bringing resident back inside after elopement |
| Dietary Cook | Found Resident #1 outside the facility and stayed with him until staff arrived | |
| Housekeeper #1 | Confirmed identity of Resident #1 outside and notified nurse | |
| Assistant Director of Nursing | ADON | Confirmed details of elopement and observations during survey |
| Director of Nursing | DON | Confirmed Resident #1 was not identified as elopement risk on admission and oversaw corrective actions |
| Maintenance Director | Inspected doors, windows, installed L-brackets on windows, and conducted elopement drills | |
| Administrator | Notified of incident, coordinated corrective actions, and conducted staff in-services | |
| Nurse Practitioner | NP | Confirmed Resident #1 was not identified as elopement risk and had no behavioral issues |
| Licensed Social Worker | Interviewed Resident #1 post-incident and found no psychosocial harm |
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to an elopement incident involving Resident #1 who exited the facility unnoticed on 3/23/25.
Complaint Details
The complaint investigation (CI) MS #28378 was triggered by a Facility Reported Incident (FRI) involving Resident #1 eloping on 3/23/25. The Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) began on 3/23/25 and were removed on 3/24/25 after corrective actions were implemented.
Findings
The facility failed to provide adequate supervision and environmental safety, resulting in Resident #1 removing a window screen and exiting the building unnoticed. Immediate Jeopardy and Substandard Quality of Care were identified but were corrected by 3/24/25 prior to the survey. Corrective actions included securing windows, increased observation, staff in-services, and elopement drills.
Deficiencies (1)
Failure to provide adequate supervision and ensure environmental safety to prevent Resident #1 from exiting the facility unnoticed.
Report Facts
Resident census: 146
Residents at risk for wandering or elopement: 58
Distance resident walked outside: 130
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Signed Evaluation Bundle indicating Resident #1 was not identified as a wander/elopement risk |
| CNA #1 | Certified Nurse Aide | Observed Resident #1 attempting to enter another resident's room and redirected him |
| Dietary Cook | Found Resident #1 outside the facility and stayed with him until staff arrived | |
| Housekeeper #1 | Confirmed Resident #1 was outside and notified nurse | |
| Nurse Supervisor | Escorted Resident #1 back into the facility | |
| Administrator | Notified of Immediate Jeopardy and incident; conducted QAPI meeting and corrective actions | |
| Director of Nursing | Confirmed Resident #1 was not at risk for elopement on admission and involved in corrective actions | |
| Maintenance Director | Inspected and secured windows, conducted elopement drills, and attended in-services | |
| Nurse Practitioner | Confirmed Resident #1 was not identified as an elopement risk | |
| Licensed Social Worker | Interviewed Resident #1 and found no psychosocial harm |
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted following an incident where Resident #1 exited the facility unnoticed and unsupervised by removing a window screen and exiting the building, posing immediate jeopardy to resident health and safety.
Complaint Details
The visit was complaint-related due to Resident #1 eloping from the facility on 3/23/25. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care. The Immediate Jeopardy was removed on 3/24/25 after corrective actions were implemented.
Findings
The facility failed to provide adequate supervision and environmental safety to prevent Resident #1 from eloping. Resident #1, with moderate cognitive impairment, exited the building unnoticed but was found unharmed approximately 130 feet from the facility. The facility implemented corrective actions including window safety modifications, staff in-services, elopement drills, and increased observation.
Deficiencies (1)
Failure to provide adequate supervision and ensure environmental safety to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Resident census: 146
Residents at risk for wandering or elopement: 58
Distance resident walked outside: 130
BIMS score: 8
Date of incident: Mar 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Observed Resident #1 attempting to enter another resident's room and redirected him | |
| Dietary Cook | Found Resident #1 outside the facility and stayed with him until staff arrived | |
| Housekeeper #1 | Confirmed Resident #1's identity outside and notified nurse | |
| Nurse on Duty | Last saw Resident #1 at 4:30 AM, administered medications, and assessed resident after elopement | |
| Assistant Director of Nursing (ADON) | Confirmed details of the elopement and corrective actions | |
| Director of Nursing (DON) | Evaluated Resident #1 on admission and confirmed no prior elopement risk | |
| Maintenance Director | Inspected windows and installed L-brackets to prevent window opening | |
| Nurse Practitioner (NP) | Confirmed Resident #1 was not identified as an elopement risk | |
| Administrator | Notified of incident, led QAPI meeting, and confirmed corrective actions | |
| Licensed Social Worker | Interviewed Resident #1 and found no psychosocial harm |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 180
Deficiencies: 2
Date: Mar 21, 2025
Visit Reason
The State Agency conducted two complaint investigations at the facility from 3/17/25 through 3/21/25 related to resident safety, neglect, and accidents.
Complaint Details
Two complaint investigations (CI MS #27598 and CI MS #27971) were conducted related to resident safety, neglect, and accidents. The facility was found to be in compliance after corrective actions were implemented on 2/14/25.
Findings
The facility failed to implement comprehensive care plan interventions and provide adequate supervision for a resident identified as a fall risk, resulting in a fall causing a mildly displaced fracture of the proximal right humerus. The responsible CNA did not follow the care plan and was terminated. The facility implemented corrective actions and was found in compliance as of 2/14/25.
Deficiencies (2)
Failed to implement comprehensive care plan interventions for a resident identified as a fall risk, resulting in a fall with injury.
Failed to provide adequate supervision to prevent a fall resulting in injury for a resident identified as a fall risk.
Report Facts
Licensed beds: 180
Resident census: 144
Sampled residents: 3
Fall incident date: Feb 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in fall incident and termination for not following care plan |
| MDS/LPN #1 | Licensed Practical Nurse | Interviewed regarding care plan adherence |
| Director of Nurses | Director of Nurses (DON) | Confirmed CNA did not follow care plan and discussed corrective actions |
| Administrator in Training | Administrator in Training (AIT) | Interviewed about fall incident and corrective actions |
| RN #2 | Registered Nurse | Reported fall incident to ADON |
| ADON | Assistant Director of Nurses | Notified of fall incident and interviewed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
The State Agency conducted two complaint investigations at the facility from 2025-03-17 through 2025-03-21 related to resident safety, neglect, and accidents.
Complaint Details
Two complaint investigations (CI MS #27598 and CI MS #27971) were conducted related to resident safety, neglect, accidents, and resident safety. The facility was found to be in compliance as of 2025-02-14 after corrective actions.
Findings
The facility failed to provide adequate supervision to prevent a fall of Resident #1, a fall risk, resulting in a mildly displaced fracture of the proximal right humerus. The fall occurred during transfer when the Certified Nurse Assistant did not follow the care plan and did not use the sit-to-stand lift because the battery was not charged. The CNA was terminated following the incident. The facility implemented corrective actions by 2025-02-14 and was found in compliance as of that date.
Deficiencies (1)
Failed to provide adequate supervision to prevent Resident #1, a fall risk, from falling and sustaining a mildly displaced fracture of the proximal right humerus.
Report Facts
Complaint Investigations: 2
Sampled residents: 3
Date of fall: Feb 13, 2025
Date corrective actions implemented: Feb 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in fall incident and terminated for not following care plan. |
| RN #2 | Registered Nurse | Assessed resident after fall and informed Nurse Practitioner and Resident Representative. |
| Director of Nurses | Director of Nurses | Confirmed accident and care plan non-compliance. |
| Administrator in Training | Administrator in Training | Provided interview details about the fall incident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following a fall incident involving Resident #1, who was identified as a fall risk and sustained a fracture during transfer by a Certified Nurse Assistant (CNA).
Complaint Details
The investigation was complaint-related due to a fall incident on 2/13/25 involving Resident #1. The complaint was substantiated as the CNA did not follow the care plan, resulting in injury. The CNA was terminated, and corrective actions were validated as implemented by 2/14/25.
Findings
The facility failed to implement comprehensive care plan interventions and provide adequate supervision to prevent Resident #1's fall, resulting in a mildly displaced fracture of the proximal right humerus. The CNA did not follow the care plan by failing to use the sit-to-stand lift, leading to the resident's injury and subsequent termination of the CNA.
Deficiencies (2)
Failed to implement comprehensive care plan interventions for a resident identified as a fall risk, resulting in a fall causing a fracture.
Failed to provide adequate supervision to prevent a fall resulting in injury to a resident.
Report Facts
Residents affected: 1
Sampled residents: 3
Date of fall: Feb 13, 2025
Date corrective actions implemented: Feb 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in fall incident and failure to follow care plan resulting in resident injury |
| MDS/LPN #1 | Licensed Practical Nurse | Interviewed regarding care plan expectations and staff training |
| Director of Nurses | Director of Nurses (DON) | Confirmed CNA #1 did not follow care plan and discussed potential prevention of incident |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Notified of fall incident and involved in resident assessment |
| Administrator in Training | Administrator in Training (AIT) | Interviewed regarding fall incident and facility response |
| RN #2 | Registered Nurse | Reported fall incident to ADON and assessed resident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 5, 2024
Visit Reason
The State Agency conducted complaint investigations at the facility from 11/4/24 through 11/5/24 related to residents left soiled and wet, assessment and notification issues, nursing services, falsification of records, and improper infection control.
Complaint Details
Investigations were conducted for three complaints: MS #26390 regarding residents left soiled and wet, MS #26704 regarding assessment, responsible party notification, and nursing services, and MS #26711 regarding falsification of records and improper infection control. No deficiencies were found.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 137
Capacity: 180
Deficiencies: 0
Date: Nov 5, 2024
Visit Reason
The State Agency conducted complaint investigations for residents left soiled and wet for an extended amount of time, assessment and notification issues, falsification of records, and improper infection control.
Complaint Details
Complaint investigations MS #26390, MS #26704, and MS #26711 were conducted regarding residents left soiled and wet, assessment and notification issues, falsification of records, and improper infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigations.
Report Facts
Licensed beds: 180
Census: 137
Inspection Report
Complaint Investigation
Census: 134
Capacity: 180
Deficiencies: 2
Date: Aug 14, 2024
Visit Reason
The State Agency conducted an investigation from 8/12/24 through 8/14/24 related to an elopement incident involving Resident #1 who exited the facility unsupervised and unnoticed by staff.
Complaint Details
Investigation MS #26122 was initiated due to a Facility Reported Incident (FRI) involving Resident #1's elopement. The Immediate Jeopardy and Substandard Quality of Care were identified and later removed after corrective actions were implemented.
Findings
The facility failed to provide adequate supervision and implement care plan interventions for Resident #1, who was identified as a wandering and elopement risk. Resident #1 left the facility unattended and was found about one mile away. The facility implemented corrective actions and the Immediate Jeopardy was removed prior to the State Agency's entrance.
Deficiencies (2)
Failure to implement care plan interventions related to wandering/elopement risk for Resident #1.
Failure to provide adequate supervision to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Facility licensed beds: 180
Resident census: 134
Distance resident found from facility (miles): 1
Temperature (degrees Fahrenheit): 92
BIMS score: 5
Number of residents added to elopement/wandering list: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Care Plan Coordinator who confirmed Resident #1 was identified as an elopement risk and care plan interventions were expected to be implemented. |
| Director of Nursing | Director of Nursing (DON) | Confirmed importance of individualized care plans and failure of staff to follow care plan interventions for Resident #1. |
| LPN #2 | Licensed Practical Nurse | Reported finding Resident #1 approximately one mile from the facility. |
| Family Nurse Practitioner | FNP | Assessed Resident #1 after elopement and found no injuries. |
| Administrator | Nursing Home Administrator | Notified State Agency and Attorney General's Office of the elopement incident and participated in QAPI meeting. |
| Rehabilitation Certified Nurse Assistant #1 | R-CNA | Reported Resident #1 missing and confirmed resident's usual location in therapy gym. |
| Social Worker | Licensed Social Worker | Assessed Resident #1 post-elopement with no psychosocial harm found. |
| CNA #2 | Certified Nursing Assistant | Assisted Resident #1 to therapy gym and advised therapy staff of resident's elopement risk. |
| Maintenance Director | Maintenance Director | Confirmed all doors were checked daily and secured; keypad removed from therapy door after incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 14, 2024
Visit Reason
The State Agency conducted a Complaint Investigation from 2024-08-12 through 2024-08-14 related to an elopement incident involving Resident #1 who exited the facility unsupervised.
Complaint Details
The complaint investigation was triggered by an elopement incident involving Resident #1. The Immediate Jeopardy and Substandard Quality of Care were identified beginning 2024-08-08. The facility's corrective actions were validated on-site on 2024-08-14, and the Immediate Jeopardy was removed on 2024-08-09.
Findings
The facility failed to provide adequate supervision to prevent Resident #1, identified as a wandering and elopement risk, from leaving the facility unnoticed and unsupervised. The resident was found approximately one mile from the facility after being missing for about 28 minutes. The facility implemented corrective actions on 2024-08-08, which led to the removal of Immediate Jeopardy status prior to the State Agency's entrance.
Deficiencies (1)
Failed to provide adequate supervision to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Distance resident found from facility: 1
Time resident missing: 28
Temperature: 92
BIMS score: 5
Number of residents reviewed: 4
Number of new residents added to elopement/wandering list: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Found Resident #1 approximately one mile from the facility and reported to DON. |
| NP | Nurse Practitioner | Assessed Resident #1 after elopement and performed labs and urinalysis. |
| Administrator | Notified of Immediate Jeopardy and led corrective actions including QAPI meeting and staff in-services. | |
| DON | Director of Nursing | Participated in root cause analysis and corrective action planning. |
| R-CNA #1 | Rehabilitation Certified Nursing Assistant | Reported Resident #1 missing and participated in search. |
| CNA #2 | Certified Nursing Assistant | Assisted Resident #1 to therapy gym and aware of elopement risk. |
| Social Worker | Interviewed Resident #1 and confirmed wandering behavior. | |
| Maintenance Director | Confirmed doors were checked daily and secured; keypad removed after incident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation triggered by an incident where Resident #1 exited the facility unsupervised and unnoticed, posing an immediate jeopardy to resident health and safety related to wandering/elopement risks.
Complaint Details
The complaint investigation revealed that Resident #1 exited the facility unsupervised on 08/08/2024, was missing for approximately 28 minutes, and was found about one mile from the facility. The facility failed to follow care plan interventions and provide adequate supervision. Immediate Jeopardy was identified and removed after corrective actions on 08/08/2024. The State Agency validated the removal on 08/14/2024.
Findings
The facility failed to implement care plan interventions and provide adequate supervision to prevent Resident #1, identified as an elopement and wandering risk, from leaving the facility unnoticed. Immediate corrective actions were taken, including staff in-service, audits, and security changes, which resolved the immediate jeopardy prior to the surveyor's entrance.
Deficiencies (2)
Failure to implement care plan interventions related to wandering/elopement risk for Resident #1.
Failure to provide adequate supervision to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Residents affected: 1
Distance resident found from facility (miles): 1
Date of incident: Aug 8, 2024
Date of survey completion: Aug 14, 2024
BIMS score: 5
Temperature (degrees Fahrenheit): 92
Number of new residents added to elopement/wandering list: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse, Care Plan Coordinator | Confirmed Resident #1 was identified as elopement risk after 06/28/24 and care plan was individualized |
| Director of Nursing | Director of Nursing (DON) | Confirmed importance of individualized care plans and failure to follow care plan interventions |
| LPN #2 | Licensed Practical Nurse | Reported finding Resident #1 walking about 1 mile from facility |
| NP | Nurse Practitioner | Assessed Resident #1 after elopement, ordered labs and UA |
| Administrator | Facility Administrator | Notified State Agency and Attorney General's office of incident; led QAPI meeting |
| Staff Development Coordinator | Staff Development Coordinator | Conducted staff in-service and elopement drills |
| Rehabilitation Certified Nursing Assistant #1 | Rehabilitation Certified Nursing Assistant | Reported Resident #1 missing and participated in search |
| Social Worker | Licensed Social Worker | Assessed Resident #1 post-incident with no psychosocial harm found |
| Maintenance Director | Maintenance Director | Confirmed all doors checked daily and keypad removed after incident |
| CNA #2 | Certified Nurse Aide | Assisted Resident #1 to therapy gym on day of incident |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 180
Deficiencies: 0
Date: Jul 22, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 7/22/24 related to resident assessment and allegations of abuse, resident not treated with respect, quality of life, and resident safety.
Complaint Details
Two complaint investigations were conducted: CI MS #25728 related to resident assessment and CI MS #25790 regarding abuse, resident not treated with respect, quality of life, and resident safety. No deficiencies were found.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 22, 2024
Visit Reason
The State Agency conducted Complaint Investigations at the facility on 7/22/24 related to resident assessment and allegations of abuse, resident not treated with respect, quality of life, and resident safety.
Complaint Details
The complaint investigations MS #25728 and MS #25790 were related to resident assessment and abuse, resident not treated with respect, quality of life, 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
Complaint Investigation
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 7/1/24 through 7/2/24 related to quality of care concerns including pain medication, hospice, hydration, odors, and wound care.
Complaint Details
Complaint Investigation MS #25496 was substantiated as the facility was found compliant with no deficiencies.
Findings
The facility was found to be in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 135
Capacity: 180
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
The State Agency conducted a complaint investigation related to quality of care regarding pain medication, hospice, hydration, odors, and wound care.
Complaint Details
Complaint Investigation MS #25496 was related to quality of care issues including pain medication, hospice, hydration, odors, and wound care. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Report Facts
Licensed beds: 180
Census: 135
Inspection Report
Complaint Investigation
Census: 136
Capacity: 180
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #25152) related to abuse at the facility.
Complaint Details
Complaint Investigation (CI MS #25152) related to abuse; no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Licensed beds: 180
Census: 136
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
The State Agency conducted a Complaint Investigation related to abuse at the facility.
Complaint Details
Complaint Investigation MS #25152 was related to abuse and was substantiated by the facility being in compliance with standards and no deficiencies cited.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility from 5/9/24 through 5/10/24 related to an annual recertification survey along with two complaint investigations conducted from 4/1/24 through 4/4/24.
Complaint Details
Two complaint investigations were conducted from 4/1/24 through 4/4/24; the follow-up revisit found the facility in compliance.
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 5/1/24.
Inspection Report
Follow-Up
Census: 137
Capacity: 180
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The State Agency conducted a follow-up revisit related to an annual recertification survey along with two complaint investigations conducted earlier in April 2024.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements and is recommended to be placed back in compliance effective May 1, 2024.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The State Agency conducted a follow-up revisit related to an annual recertification survey along with two complaint investigations conducted earlier in April 2024.
Complaint Details
Two complaint investigations were conducted from April 1, 2024 through April 4, 2024; the follow-up revisit determined compliance.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, and it is recommended to be placed back in compliance effective May 1, 2024.
Report Facts
Complaint Investigations: 2
Inspection Report
Follow-Up
Census: 137
Capacity: 180
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The State Agency conducted a follow-up revisit related to an annual recertification survey along with two Complaint Investigations conducted earlier in April 2024.
Complaint Details
Two Complaint Investigations were conducted from 4/1/24 through 4/4/24; the follow-up revisit found the facility in compliance.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements and is recommended to be placed back in compliance effective May 1, 2024.
Report Facts
Licensed beds: 180
Census: 137
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 8, 2024
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 5/8/24 related to quality of care concerning a feeding tube.
Complaint Details
Complaint Investigation MS #24948 was investigated for quality of care related to a feeding tube and found no deficiencies.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited during this investigation, although the facility remains out of compliance due to deficiencies from a prior survey on 4/4/2024.
Inspection Report
Complaint Investigation
Census: 137
Capacity: 180
Deficiencies: 0
Date: May 8, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24948, at the facility on 5/8/24 related to quality of care concerning a feeding tube.
Complaint Details
Complaint Investigation MS #24948 was investigated for quality of care related to a feeding tube and found no deficiencies during this visit.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited. However, the facility remains out of compliance due to deficiencies from the prior 4/4/2024 survey.
Report Facts
Licensed beds: 180
Census: 137
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 4, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with two complaint investigations related to an injury of unknown origin at the facility from 4/1/24 to 4/4/24.
Complaint Details
Two complaint investigations (CI MS #24542 and CI MS #24561) were conducted related to an injury of unknown origin.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and cited for multiple deficiencies including residents' rights, activities of daily living, urinary incontinence, safe food handling, pest control, and infection control.
Deficiencies (6)
Failed to ensure resident council concerns were resolved in a timely manner for six months, including unresolved grievances related to housekeeping, laundry, and dietary services.
Failed to provide adequate assistance with activities of daily living, specifically showers and baths for residents requiring assistance.
Failed to ensure indwelling catheter tubing was secured with a leg strap to prevent complications.
Failed to store food in accordance with professional standards, including unlabeled, undated, expired food items, and overly ripe produce.
Failed to provide effective pest control related to roaches observed inside the facility on multiple days.
Failed to handle dinnerware properly to prevent spread of infection for a resident on contact isolation; washable dinnerware was used instead of disposable items.
Report Facts
Complaint Investigations: 2
Resident Council grievances reviewed: 6
Showers or baths documented for Resident #53: 2
Showers or baths documented for Resident #74: 5
Pest control service date: Mar 20, 2024
Pest control additional service date: Apr 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Attended emergency Resident Council meeting and collaborated on grievance resolution. | |
| Director of Nursing | DON | Provided education on ADL performance and catheter care; interviewed regarding deficiencies. |
| Certified Dietary Manager | CDM | Responsible for food safety and handling; acknowledged unlabeled and expired food items. |
| Activities Director | AD | Facilitated Resident Council meetings and was educated on grievance reporting. |
| Licensed Practical Nurse #6 | LPN | Interviewed regarding ADL care and shower schedule. |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding resident bathing and showering. |
| Dietary Manager | DM | Collaborated on resident grievances regarding food quality. |
Inspection Report
Annual Inspection
Census: 144
Capacity: 180
Deficiencies: 16
Date: Apr 4, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with two complaint investigations related to an injury of unknown origin and compliance with Medicare and Medicaid participation requirements.
Complaint Details
Two complaint investigations were conducted related to an injury of unknown origin. The facility was found not in compliance with Medicare and Medicaid participation requirements as a result of these complaints.
Findings
The facility was found not in compliance with multiple regulatory requirements including resident rights, safe environment, transfer/discharge notices, PASARR screening, comprehensive care plans, ADL care, catheter care, nurse staffing postings, medication labeling and storage, food safety, QAPI program effectiveness, infection control, immunizations, and pest control.
Deficiencies (16)
Failed to ensure resident council concerns were resolved in a timely manner for six months.
Failed to ensure residents' rights for a clean and comfortable environment regarding soiled privacy curtains for two residents.
Failed to provide written notification of facility-initiated transfers to residents or representatives for five residents.
Failed to provide written notification of the bed hold policy to residents or representatives upon transfer for five residents.
Failed to ensure accurate PASARR screening for a resident with major mental illness.
Failed to implement comprehensive care plan intervention related to securing device for indwelling catheter tubing for one resident.
Failed to provide ADL care related to showers and baths for two residents who require assistance.
Failed to ensure indwelling catheter tubing was secured to prevent complications for one resident.
Failed to post daily nurse staffing information for three of four days of survey.
Failed to provide an opened date for a multi-use medication vial and failed to ensure medications, food, and biohazard substances were not stored together in two medication rooms.
Failed to store food in accordance with professional standards for food service safety related to undated, unlabeled, expired food items and overly ripe produce.
Failed to handle dinnerware in a manner to prevent spread of infection for a resident on contact isolation.
Failed to provide influenza and pneumococcal vaccines to residents who requested the vaccine for four residents.
Failed to sustain an effective QAPI program during leadership transitions and failed to maintain implemented procedures and monitor interventions from previous citations.
Failed to establish and maintain an infection prevention and control program to prevent spread of infection.
Failed to maintain an effective pest control program related to roaches observed in the facility.
Report Facts
Deficiencies cited: 16
Beds licensed: 180
Resident census: 144
Plan of correction completion dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in multiple interviews related to findings and facility compliance. | |
| Director of Nursing | DON | Named in multiple interviews related to findings and facility compliance. |
| Business Office Manager | BOM | Named in relation to transfer/discharge notification findings. |
| Assistant Administrator | AA | Named in relation to transfer/discharge notification findings. |
| Licensed Master Social Worker | LMSW | Named in relation to PASARR screening findings. |
| Certified Nurse Aide #3 | CNA | Named in relation to ADL care and catheter care findings. |
| Registered Nurse #5 | RN | Named in relation to catheter care findings. |
| Licensed Practical Nurse #6 | LPN | Named in relation to ADL care and catheter care findings. |
| Certified Dietary Manager | CDM | Named in relation to food safety and infection control findings. |
| Assistant Director of Nursing | ADON | Named in relation to multiple findings including immunizations, catheter care, and infection control. |
| Infection Preventionist | IP | Named in relation to infection control findings. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with two complaint investigations related to an injury of unknown origin at the facility from April 1, 2024 to April 4, 2024.
Complaint Details
Two complaint investigations (MS #24542 and MS #24561) were conducted related to an injury of unknown origin.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, resulting in citations including M500, M610, M620, M815, M970, and M1570.
Inspection Report
Annual Inspection
Census: 144
Capacity: 180
Deficiencies: 3
Date: Apr 4, 2024
Visit Reason
The State Agency conducted an annual recertification survey along with two complaint investigations related to an injury of unknown origin at the facility from 4/1/24 to 4/4/24.
Complaint Details
Two complaint investigations (CI MS #24542 and CI MS #24561) were conducted related to an injury of unknown origin. The investigation was found deficient for Resident #242 due to incomplete investigation procedures.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to failure to conduct thorough investigations of injuries, failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, and failure to ensure residents' rights to a clean environment. Specific citations included F610 for investigation failures and F865 for QAPI program deficiencies.
Deficiencies (3)
Failed to complete a thorough investigation regarding an injury of unknown origin for one resident, including failure to interview all relevant residents and outside agencies.
Failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, including sustaining the program during leadership transitions and monitoring interventions.
Failed to ensure residents' rights for a clean and comfortable environment regarding soiled privacy curtains for two residents.
Report Facts
Licensed beds: 180
Census: 144
Number of residents reviewed for accidents: 6
Residents with soiled privacy curtains: 2
Deficient practice citations related to QAPI: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to failure to conduct thorough investigation and QAPI program oversight | |
| Regional Director of Operations | Educated Administrator and QA committee on CMS guidelines for investigations and QAPI program | |
| Licensed Social Worker | Provided information about Resident #242's hospital transfer and injuries |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements, including investigation of resident injuries and quality assurance processes.
Findings
The facility failed to complete a thorough investigation regarding an injury of unknown origin for one resident, Resident #242, who had bilateral pubic ramus fractures. Additionally, the Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain the program during leadership transitions and did not maintain or monitor interventions from previous citations, showing a pattern of ineffective quality assurance.
Deficiencies (3)
Failed to complete a thorough investigation regarding an injury of unknown origin for Resident #242 with bilateral pubic ramus fractures.
Failed to ensure residents' rights for a clean and comfortable environment regarding soiled privacy curtains for two residents (#6 and #27).
Failed to sustain the Quality Assurance and Performance Improvement (QAPI) program during leadership transitions and failed to maintain and monitor interventions from previous citations.
Report Facts
Residents reviewed for accidents: 6
Residents sampled for privacy curtain issue: 30
Residents affected by privacy curtain deficiency: 2
Deficient practice citations: 16
Recited deficiencies from previous survey: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Social Worker | LSW | Provided interview information regarding Resident #242's hospital transfer and x-rays |
| Administrator | Facility Administrator | Interviewed regarding Resident #242's injury investigation and QAPI committee activities |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with federal regulations related to resident rights, care, safety, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to timely resolve resident council concerns, maintain a clean and comfortable environment, provide timely transfer notifications, implement PASARR screening accurately, follow care plans for catheter care, provide adequate ADL care including showers, maintain proper medication storage and labeling, ensure infection control practices especially for contact isolation, provide timely vaccinations, sustain an effective QAPI program, and maintain an effective pest control program.
Deficiencies (15)
Failed to ensure resident council concerns were resolved in a timely manner for six months.
Failed to ensure residents' rights were honored for a clean and comfortable environment, evidenced by soiled privacy curtains for two residents.
Failed to provide timely written notification of facility-initiated transfers to residents or representatives for five residents.
Failed to provide written notification of bed hold policy to residents or representatives upon transfer for five residents.
Failed to ensure PASARR screening was reviewed for accuracy and initiated for a resident with major mental illness.
Failed to implement a comprehensive care plan intervention related to securing indwelling catheter tubing for one resident.
Failed to provide adequate ADL care related to showers and baths for two residents.
Failed to ensure indwelling catheter tubing was secured to prevent complications for one resident.
Failed to post daily nurse staffing information for three of four days of survey.
Failed to provide an opened date for a multi-use medication vial and failed to ensure medications, food, and biohazard substances were not stored together in two medication rooms.
Failed to store food in accordance with professional standards related to undated, unlabeled, expired food items and overly ripe produce.
Failed to sustain an effective QAPI program to address previously cited deficiencies related to residents' rights/environment and investigations.
Failed to handle dinnerware in a manner to prevent possible spread of infection for a resident on contact isolation.
Failed to provide influenza and pneumococcal vaccines to residents who requested them for four residents.
Failed to provide effective pest control related to roaches observed inside the facility.
Report Facts
Months resident council concerns unresolved: 6
Residents affected by soiled curtains: 2
Residents affected by transfer notification deficiency: 5
Residents affected by bed hold notification deficiency: 5
Residents affected by vaccination deficiency: 4
Residents affected by ADL care deficiency: 2
Residents affected by infection control deficiency: 1
Residents affected by catheter care deficiency: 1
Days missing nurse staffing posting: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed receipt of resident council concerns, transfer notification lapses, vaccination issues, and QAPI committee discussions | |
| Director of Nursing | DON | Confirmed deficiencies in catheter care, vaccination, infection control, ADL care, and pest control |
| Business Office Manager | BOM | Responsible for mailing transfer and bed hold notifications; had health condition impacting performance |
| Dietary Manager | DM | Confirmed resident food complaints and lack of follow-up |
| Activities Director | AD | Confirmed resident complaints about food and lack of documentation |
| Licensed Practical Nurse | LPN #6 | Observed contact isolation meal tray issue |
| Certified Nurse Aide | CNA #3 | Observed catheter care and ADL care deficiencies |
| Infection Preventionist | IP | Reported uncertainty about contact isolation meal handling |
| Social Services Director | SSD | Explained family notification process for hospital transfers |
| Licensed Practical Nurse | LPN #7 | Explained shower schedule and staff responsibilities |
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
Survey conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility meets all applicable Federal, State, and local emergency preparedness requirements as of the survey date.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 3/6/24 regarding misappropriation of property and medication improperly administered.
Complaint Details
Investigation MS #23862 was for misappropriation of property and medication improperly administered; no deficiencies were found.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 144
Capacity: 180
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #23862) at the facility on 3/6/24 for misappropriation of property and medication improperly administered.
Complaint Details
Complaint Investigation (CI MS #23862) for misappropriation of property and medication improperly administered; no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements. No deficiencies were cited.
Report Facts
Licensed beds: 180
Census: 144
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
The State Agency conducted two complaint investigations related to pressure sores and assessment/monitoring, and resident abuse related to assessment/monitoring at the facility on 2024-01-02.
Complaint Details
Two complaint investigations (CI MS #23391 and CI MS #23634) were conducted. CI MS #23634 was related to pressure sores and assessment/monitoring, and CI MS #23391 was related to resident abuse and assessment/monitoring. Both complaints were investigated with no deficiencies found.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 134
Capacity: 180
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
The State Agency conducted two complaint investigations related to pressure sores and assessment/monitoring, and resident abuse related to assessment/monitoring.
Complaint Details
Two complaint investigations (CI MS #23391 and CI MS #23634) were conducted. CI MS #23634 concerned pressure sores and assessment/monitoring, and CI MS #23391 concerned resident abuse related to assessment/monitoring. Both complaints were investigated with no deficiencies found.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigations.
Report Facts
Licensed beds: 180
Census: 134
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22657, related to injury of unknown origin and resident not assessed.
Complaint Details
Complaint MS #22657 was investigated related to injury of unknown origin and resident not assessed. No deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
The State Agency conducted a complaint investigation related to injury of unknown origin and resident not assessed.
Complaint Details
Complaint Investigation MS #22657 was related to injury of unknown origin and resident not assessed; no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Licensed beds: 180
Census: 140
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 21, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22100, at the facility related to neglect, pressure sores, pain, and resident rights/not smoking.
Complaint Details
Complaint Investigation MS #22100 was related to neglect, pressure sores, pain, and resident rights/not smoking. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 138
Capacity: 180
Deficiencies: 0
Date: Aug 21, 2023
Visit Reason
The State Agency conducted a complaint investigation related to neglect, pressure sores, pain, and resident rights/not smoking.
Complaint Details
Complaint Investigation (CI), MS #22100, investigated neglect, pressure sores, pain, and resident rights/not smoking; no deficiencies were found.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Report Facts
Licensed beds: 180
Census: 138
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
The State Agency conducted Complaint Investigations at the facility from 6/13/23 through 6/15/23 related to discharge rights, resident left wet for extended periods, pressure sores, turning/repositioning, notification of a resident's change in condition, and the physical environment of the facility.
Complaint Details
The investigations covered complaints MS #21058 (discharge rights), MS #21112 (resident left wet for extended periods), MS #21208 (pressure sores, turning/repositioning, notification of change in condition), and MS #21397 (pressure sores and physical environment). No deficiencies were found.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited during the investigations.
Inspection Report
Complaint Investigation
Census: 145
Capacity: 180
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
The State Agency conducted a Focused Infection Control survey and Complaint Investigations related to discharge rights, resident left wet for extended periods, pressure sores, turning/repositioning, notification of a resident's change in condition, and the physical environment of the facility.
Complaint Details
Investigations were conducted for complaints MS #21058 (discharge rights), MS #21112 (resident left wet for extended periods), MS #21208 (pressure sores, turning/repositioning, notification of change in condition), and MS #21397 (pressure sores and physical environment). No deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the investigation.
Report Facts
Licensed beds: 180
Census: 145
Inspection Report
Complaint Investigation
Census: 145
Capacity: 180
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
The State Agency conducted a Focused Infection Control survey and Complaint Investigations related to discharge rights, resident left wet for extended periods, pressure sores, turning/repositioning, notification of a resident's change in condition, and the physical environment of the facility.
Complaint Details
The survey investigated complaints MS #21058 (discharge rights), MS #21112 (resident left wet for extended periods), MS #21208 (pressure sores, turning/repositioning, notification of change in condition), and MS #21397 (pressure sores and physical environment). No deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the survey.
Report Facts
Licensed beds: 180
Census: 145
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 6/13/23 through 6/15/23.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
The document is an annual inspection report for The Pillars of Biloxi nursing home, conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 1
Date: Mar 20, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 03/13/2023 and 03/19/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure 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
Reporting period: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 3, 2023
Visit Reason
The State Agency conducted a Complaint Investigation from 2/2/23 through 2/3/23 related to the facility's environment, offensive odors, rehabilitation services, resident falls, inappropriate feeding assistance, and billing.
Complaint Details
The complaint investigation included MS #20281, MS #20268, and MS #19966. MS #20268 was related to environmental concerns, offensive odors, rehabilitation services, resident falls, inappropriate feeding assistance, and billing. The facility was found non-compliant for environmental issues but compliant for administration and resident neglect.
Findings
The facility was found not in compliance with Minimum Standards related to the physical environment, specifically inadequate housekeeping and maintenance services in three of 25 resident rooms and the East Wing lounge. Issues included rusty and damaged overbed tables, missing bed parts, discolored floors, holes in walls, spider webs, and general poor cleanliness. The facility initiated repairs and cleaning and implemented monitoring and quality improvement plans.
Deficiencies (1)
Failed to provide adequate housekeeping and maintenance services necessary to ensure a safe, clean environment for three of 25 resident rooms and the East Wing lounge.
Report Facts
Resident rooms affected: 3
Number of residents mentioned: 4
Dates for plan of correction: Mar 30, 2023
Dates for cleaning completion: Feb 3, 2023
BIMS scores: 12
BIMS scores: 15
BIMS scores: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Interviewed regarding cleaning duties and observations of stains and discoloration. | |
| Maintenance Supervisor | Responsible for maintenance repairs and explained overbed tables and bed replacement needs. | |
| Housekeeping Supervisor | Educated housekeeping staff on proper procedures and responsible for cleanliness assessments. | |
| Licensed Practical Nurse #1 | LPN | Assigned to East Wing residents and interviewed about observations of maintenance issues. |
| Administrator | Administrator | Became administrator on January 21, 2023, acknowledged maintenance and housekeeping issues and committed to improvements. |
| Floor Technician | Responsible for cleaning floors in common areas and hallways; reported floor machine broken for about a month. |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 180
Deficiencies: 1
Date: Feb 3, 2023
Visit Reason
The State Agency conducted a complaint investigation from 2/2/23 through 2/3/23 related to the facility's environment, offensive odors, rehabilitation services, resident falls, inappropriate feeding assistance, and billing.
Complaint Details
The complaint investigation included MS #20281, MS #20268, and MS #19966. MS #20268 was related to the facility's environment, offensive odors, rehabilitation services, resident falls, inappropriate feeding assistance, and billing. The facility was found non-compliant for MS #20268 but compliant for MS #20281 (Administration) and MS #19966 (resident neglect).
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to deficiencies in maintaining a safe, clean, comfortable, and homelike environment, specifically inadequate housekeeping and maintenance services affecting several resident rooms and common areas.
Deficiencies (1)
Failed to provide adequate housekeeping and maintenance services necessary to ensure a safe, clean environment in three of 25 resident rooms on the East Wing and the East Wing lounge, including issues with overbed tables, bed repairs, rust, spider webs, holes in walls, and discolored floors.
Report Facts
Licensed beds: 180
Resident census: 142
Resident rooms inspected: 25
Residents affected: 4
Plan of correction completion date: Mar 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Interviewed regarding cleaning duties and observations of room conditions | |
| Licensed Practical Nurse #1 | LPN | Confirmed routine assignments and observations of resident rooms |
| Maintenance Supervisor | Provided information on maintenance issues and repair plans | |
| Housekeeping Supervisor | Responsible for housekeeping staff education and inspection rounds | |
| Administrator | Administrator | Confirmed observations and committed to improvements; started approximately three weeks prior to inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to the facility.
Complaint Details
The complaint survey was completed on 02/03/23 and the information provided confirmed compliance; the facility was recommended to be placed back in compliance effective 03/03/23.
Findings
The State Agency conducted a desk review of information related to the complaint survey and confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The facility was recommended to be placed back in compliance effective 03/03/23.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 02/03/23 to verify corrective measures taken by the facility.
Complaint Details
The visit was complaint-related, triggered by a complaint survey completed on 02/03/23. The facility's corrective actions were reviewed and found satisfactory.
Findings
The facility provided information confirming that measures were implemented to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 03/03/23.
Report Facts
Survey completion date: Mar 14, 2023
Complaint survey date: Feb 3, 2023
Inspection Report
Routine
Deficiencies: 6
Date: Feb 2, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, and homelike environment for residents, focusing on housekeeping and maintenance services.
Findings
The facility failed to provide adequate housekeeping and maintenance services in multiple resident rooms and common areas, including issues such as rusty overbed tables, missing bed parts, spider webs, holes in walls, discolored floors, and unclean surfaces. Several maintenance and housekeeping deficiencies were observed and confirmed by staff and residents.
Deficiencies (6)
Unstable, wobbly overbed table with missing laminate and rust in Resident #3's room.
Rusty overbed base, spider webs, and easily wiped brown/gray substance on floor in Resident #4's room.
Missing footboard and crank handle on Resident #5's bed; missing air conditioner cover with a plant growing through it.
Rust-colored discoloration around toilet floor and bolts, hole in bathroom wall, loose baseboard, and gray/black substance on bathroom door between Residents #4, #5, and #6.
Scuffed, scratched, and dirty exit door and walls in the East Wing Resident Lounge with spider webs and peeling paint.
Sheetrock collapsed inward below window near exit door; baseboard pulled away; stained floors with easily wiped grayish substance in Resident Lounge.
Report Facts
Residents affected: 4
Resident rooms inspected: 25
Hole size: 144
Paint damage size: 93.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Interviewed about cleaning duties and observations of discoloration in Resident #3's room | |
| Director of Nurses (DON) | Director of Nurses | Interviewed and confirmed observations of rusty tables, spider webs, and maintenance issues |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed about routine care and observations of maintenance issues in residents' rooms |
| Housekeeping Supervisor | Interviewed about housekeeping assignments, cleaning standards, and observations of spider webs and cleaning deficiencies | |
| Maintenance Supervisor | Interviewed about maintenance issues, inability to repair overbed tables, and need to replace beds and paint doors | |
| Administrator | Administrator | Confirmed maintenance and housekeeping issues and stated commitment to improvement |
| Floor Technician | Interviewed about floor cleaning responsibilities and broken floor machine |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 11/29/22 through 11/30/22 related to complaints of resident abuse.
Complaint Details
Complaint Investigation MS #19906 and MS #19930; complaints related to resident abuse were not substantiated.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. The complaints related to resident abuse were not substantiated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 135
Capacity: 180
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 11/29/22 through 11/30/22 related to complaints of resident abuse.
Complaint Details
Complaint Investigation MS #19906 and MS #19930; complaints of resident abuse were not substantiated.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints of resident abuse were not substantiated and no deficiencies were cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 2022-09-13 to verify corrective measures taken by the facility.
Complaint Details
The visit was related to a complaint survey completed on 2022-09-13. The desk review confirmed corrective actions were implemented and compliance was restored.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2022-10-22.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 13, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 09/13/22 to determine compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
The visit was complaint-related, and the facility was found to be in compliance based on the desk review.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 10/22/22.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
The State Agency conducted a complaint investigation (MS #19537) at the facility from 9/12/2022 to 9/13/2022 due to concerns related to the physical environment.
Complaint Details
The complaint investigation MS #19537 was substantiated related to physical environment issues including flooding, damaged walls and ceilings, and lack of timely repairs.
Findings
The facility failed to maintain and provide a clean, sanitary, and home-like environment in six rooms on the Rehabilitation Unit, with issues including damaged walls, ceilings, flooding, and broken fixtures. These deficiencies had the potential to impact 26 residents. Maintenance and administrative staff acknowledged the environmental problems and have initiated repairs and monitoring plans.
Deficiencies (1)
Failure to maintain walls and ceilings in good repair, including holes, chipped paint, and water damage in six rooms on the Rehabilitation Unit.
Report Facts
Rooms with deficiencies: 6
Residents potentially impacted: 26
Dates of observation/interviews: Sep 12, 2022
Dates of observation/interviews: Sep 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Confirmed awareness of environmental problems and advised Maintenance Department to focus on serious issues like flooding. |
| Administrator in Training | Administrator in Training (AIT) | Spoke with residents to address environmental concerns and collaborated on prioritizing repairs. |
| Maintenance Supervisor | Maintenance Supervisor | Collaborated on prioritizing repairs and responsible for maintenance service and monitoring. |
| Maintenance Assistant | Maintenance Assistant | Assisted with repairs and maintenance tasks. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Works on Rehabilitation Unit; aware of flooding but has not documented environmental issues due to workload. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Trained to document environmental issues and has used maintenance logs to document concerns. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Trained to document environmental issues but has not documented due to workload. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Documents environmental issues in maintenance book and aware of flooding and damage. |
| Floor Technician | Floor Technician | Noticed flooding and peeling walls but has not documented issues. |
| Housekeeper #2 | Housekeeper | Aware of environmental issues and instructed to document them. |
| Housekeeper #3 | Housekeeper | New employee; aware of environmental issues but has not documented them. |
| Director of Nursing | Director of Nursing (DON) | Confirmed awareness of environmental issues and instructed staff to document all issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
The State Agency conducted a complaint investigation (MS #19537) at the facility from 9/12/2022 to 9/13/2022 due to concerns related to the physical environment.
Complaint Details
The complaint investigation MS #19537 was substantiated related to physical environment issues including flooding, damaged walls and ceilings, and broken fixtures in resident rooms.
Findings
The facility failed to maintain a clean, sanitary, and home-like environment in six rooms on the Rehabilitation Unit, with issues including damaged walls, ceilings, flooding, and broken fixtures. These deficiencies potentially impacted 26 residents. Maintenance and administrative staff acknowledged the problems and initiated repairs and monitoring plans.
Deficiencies (1)
Facility failed to maintain and provide a clean, sanitary, and home-like environment for six rooms on the Rehabilitation Unit, including damaged walls, ceilings, flooding, and broken fixtures.
Report Facts
Rooms with deficiencies: 6
Residents potentially impacted: 26
Dates of survey: 2022-09-12 to 2022-09-13
BIMS scores: 15
BIMS scores: 15
BIMS scores: 13
BIMS scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Confirmed awareness of environmental problems and advised maintenance focus on flooding and repairs. |
| Administrator in Training | Administrator in Training (AIT) | Spoke with residents about environmental concerns and collaborated on prioritizing repairs. |
| Maintenance Supervisor | Maintenance Supervisor | Collaborated on prioritizing repairs and responsible for maintenance service and repairs. |
| Maintenance Assistant | Maintenance Assistant | Assisted with repairs and maintenance tasks. |
| Director of Nursing | Director of Nursing (DON) | Confirmed environmental issues and instructed staff to document maintenance concerns. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Reported no documentation of environmental issues due to workload. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Trained to document environmental issues and has used maintenance logs. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Trained to document environmental issues but has not documented due to workload. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Documents environmental issues in maintenance book and aware of facility flooding. |
| Housekeeper #2 | Housekeeper | Aware of environmental issues and instructed to document them. |
| Housekeeper #3 | Housekeeper | New employee aware of environmental issues but has not documented them. |
| Floor Technician | Floor Technician | Noticed flooding and peeling walls but has not documented issues. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 2
Date: Sep 12, 2022
Visit Reason
The State Agency conducted a complaint survey (CI MS #19537) at the facility on 9/12/22 through 9/13/22 to investigate environmental concerns and compliance with Medicare and Medicaid participation requirements.
Complaint Details
The complaint investigation (CI MS #19537) was substantiated related to Physical Environment deficiencies, including unresolved quality deficiencies involving environmental concerns.
Findings
The facility failed to maintain a safe, clean, comfortable, and home-like environment in six rooms on the Rehabilitation Unit, with issues including damaged drywall, flooding, broken fixtures, and paint chipping. The facility also failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program to address these environmental deficiencies, which had been previously cited in the last annual recertification survey.
Deficiencies (2)
Facility failed to maintain a clean, sanitary, and home-like environment in six rooms on the Rehabilitation Unit (Rooms 303, 304, 311, 314, 323, and 327) with issues such as drywall damage, flooding, broken fixtures, and paint chipping.
Facility's QAPI Committee failed to sustain the program during leadership transitions and did not maintain or monitor interventions related to environmental deficiencies previously cited.
Report Facts
Licensed capacity: 180
Census: 140
Number of affected rooms: 6
Number of residents potentially impacted: 26
Inspection Report
Complaint Investigation
Census: 127
Capacity: 180
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The State Agency conducted a Complaint Investigation along with a COVID-19 Focused Infection Control survey at the facility from 7/14/22 through 7/19/22.
Complaint Details
Complaints MS# 19377 (tracheostomy care), MS# 18794 (neglect and residents being left wet), MS# 18801 (physical environment), MS# 19374 (neglect/falls), and MS# 19375 (abuse) were all investigated and found not substantiated.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. Multiple complaints were investigated and none were substantiated, including allegations related to tracheostomy care, neglect, physical environment, falls, and abuse.
Report Facts
Licensed beds: 180
Census: 127
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 7/14/22 through 7/19/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 127
Capacity: 180
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The State Agency conducted a Complaint Investigation along with a COVID-19 Focused Infection Control survey at the facility from 7/14/22 through 7/19/22.
Complaint Details
Complaints investigated included MS# 18794, 18801, 19374, 19375, and 19377. None were substantiated.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. Multiple complaints were investigated and none were substantiated, including allegations related to tracheostomy care, neglect, physical environment, falls, and abuse.
Report Facts
Licensed beds: 180
Census: 127
Inspection Report
Routine
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 7/14/22 through 7/19/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 7/14/22 through 7/19/22 covering multiple complaint numbers.
Complaint Details
Complaint Investigation conducted for MS# 18794, MS# 18801, MS# 19374, MS# 19375, and MS# 19377; no deficiencies were cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 7/14/22 through 7/19/22 based on multiple complaint numbers.
Complaint Details
Complaint Investigation conducted under MS# 18794, MS# 18801, MS# 19374, MS# 19375, and MS# 19377; facility found compliant with no deficiencies.
Findings
The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 7/14/22 through 7/19/22 involving multiple complaint numbers.
Complaint Details
Complaint Investigation (CI), MS# 18794, MS# 18801, MS# 19374, MS# 19375, and MS# 19377; no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2022
Visit Reason
The State Survey Agency conducted a Complaint Investigation at the facility on 05/03/22 for MS #18710 to investigate allegations related to resident assessments, medication administration, hydration, weight loss assessments, feeding assistance, and pressure sore precautions.
Complaint Details
Complaint investigation for MS #18710 was conducted and found unsubstantiated due to insufficient evidence of negligence related to resident care issues.
Findings
The complaint was not substantiated due to lack of sufficient evidence of negligence. No deficiencies were cited during this investigation, but the facility remains out of compliance due to deficiencies cited in a prior survey on 03/16/2022.
Report Facts
Previous survey date: Mar 16, 2022
Inspection Report
Complaint Investigation
Census: 141
Capacity: 180
Deficiencies: 0
Date: May 3, 2022
Visit Reason
The State Survey Agency conducted a complaint investigation at the facility on 05/03/22 for MS #18710 to determine if the facility was negligent in resident assessments, medication administration, hydration, weight loss assessments, feeding assistance, and pressure sore precautions.
Complaint Details
Complaint investigation for allegations including failure to assess residents after change in condition, medication errors, failure to offer water, failure to assess weight loss, inappropriate feeding assistance, and lack of pressure sore precautions; complaint was not substantiated.
Findings
The complaint was not substantiated due to lack of sufficient evidence. No deficiencies were cited during this investigation, but the facility remains out of compliance due to deficiencies cited in a prior survey on 03/16/2022.
Report Facts
Census: 141
Total licensed capacity: 180
Inspection Report
Annual Inspection
Census: 133
Capacity: 180
Deficiencies: 1
Date: Mar 16, 2022
Visit Reason
The State Survey Agency conducted an annual recertification inspection along with two complaint investigations from 03/06/2022 through 03/11/2022, and a follow-up investigation on 03/16/2022 regarding a complaint of abuse.
Complaint Details
Two complaint investigations (CI MS #18546 and CI MS #18547) were conducted; both were substantiated. The complaint regarding abuse (CI MS #18593) was investigated on 03/16/22 and was not substantiated.
Findings
The facility was found not in compliance with state licensure requirements, with citations including issues related to food palatability. Four residents reported tasteless food, and observations confirmed the food was bland and not seasoned properly. The complaint regarding abuse was not substantiated.
Deficiencies (1)
Food preparation failed to ensure food was palatable and satisfactory for four of 32 sampled residents.
Report Facts
Residents sampled for food palatability: 32
Residents with food palatability issues: 4
Census: 133
Total bed capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food palatability concerns and confirmed food was bland | |
| Administrator | Interviewed and acknowledged no policy related to palatable food and awareness of resident complaints |
Inspection Report
Annual Inspection
Census: 133
Capacity: 180
Deficiencies: 3
Date: Mar 16, 2022
Visit Reason
The State Survey Agency conducted an annual recertification survey along with two complaint investigations from 03/06/2022 through 03/11/2022, and a follow-up investigation on 03/16/2022 regarding a complaint of abuse.
Complaint Details
Two complaint investigations were conducted (CI MS #18546 and CI MS #18547). CI #18546 related to medication diversion was substantiated with citations F609 and F610. CI #18547 related to food palatability was substantiated with citation F804. A third complaint investigation (CI MS #18593) regarding abuse was not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with multiple deficiencies cited including medication diversion and food palatability issues. The complaint of abuse was not substantiated. The facility failed to timely report and thoroughly investigate allegations of medication diversion and had issues with food palatability.
Deficiencies (3)
Failure to report an allegation of possible medication diversion to the State Agency in a timely manner.
Failure to conduct a thorough investigation related to misappropriation of medication allegations.
Food served was not palatable or satisfactory for four sampled residents.
Report Facts
Deficiencies cited: 10
Deficiencies cited: 2
Deficiencies cited: 1
Census: 133
Total capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | LPN | Named in medication diversion allegation and investigation. |
| Administrator | Instructed investigation of medication diversion allegations and failed to report timely. | |
| Director of Nursing | DON | Involved in investigation of medication diversion allegations and provided education to LPN #7. |
| Licensed Practical Nurse #2 | LPN/Transitional Care Unit Manager | Assisted in narcotic log review and investigation of medication diversion allegations. |
| Dietary Manager | DM | Acknowledged food palatability concerns and provided education to dietary staff. |
Inspection Report
Annual Inspection
Census: 133
Capacity: 180
Deficiencies: 3
Date: Mar 16, 2022
Visit Reason
The State Survey Agency conducted an annual recertification survey along with two complaint investigations from 03/06/2022 through 03/11/2022, and a follow-up investigation on 03/16/2022 regarding a complaint of abuse.
Complaint Details
Two complaint investigations were conducted: CI MS #18546 related to medication diversion and CI MS #18547 related to food palatability. The SSA substantiated the medication diversion complaint but found the facility failed to report and investigate properly. The complaint regarding abuse (CI MS #18593) was not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with multiple deficiencies cited including medication diversion and food palatability issues. The complaint of abuse was not substantiated. Deficiencies included failure to report and investigate medication diversion allegations thoroughly and failure to provide palatable food.
Deficiencies (3)
Failure to report an allegation of possible medication diversion to the State Agency in a timely manner.
Failure to conduct a thorough investigation related to misappropriation of medication allegations.
Failure to ensure food was palatable and satisfactory for residents.
Report Facts
Deficiencies cited: 12
Residents sampled: 32
Residents with food palatability issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | LPN | Named in medication diversion allegation and investigation. |
| Administrator | Responsible for reporting and investigation decisions related to medication diversion allegations. | |
| Director of Nursing | DON | Involved in investigation and reporting of medication diversion allegations. |
| Regional Director of Operations | RDO | Provided in-service training to Administrator on reporting and investigation policies. |
| Dietary Manager | DM | Named in food palatability deficiency and corrective actions. |
| LPN #2 | TCU Manager | Assisted in narcotic log review and investigation of medication diversion allegations. |
| Pharmacy Consultant | Reviewed narcotic logs and medication administration records during investigation. |
Inspection Report
Annual Inspection
Census: 133
Capacity: 180
Deficiencies: 5
Date: Mar 16, 2022
Visit Reason
The State Survey Agency conducted an annual recertification survey along with two complaint investigations from 03/06/2022 through 03/11/2022, and a follow-up investigation on 03/16/2022.
Complaint Details
Two complaint investigations were substantiated: one related to physical restraints and another related to the palatability of food. A third complaint regarding abuse was not substantiated.
Findings
The facility was found not in compliance with state licensure requirements, citing multiple deficiencies including improper use of physical restraints, inadequate fall risk management, unsafe food handling and preparation, and poor maintenance of shower rooms.
Deficiencies (5)
Failed to identify the use of a Geri chair with a tray as a physical restraint for one resident.
Failed to reassess fall risk, determine root cause of a fall, and implement interventions for one resident.
Failed to clean thermometer between food items and failed to record tray line temperatures for breakfast and lunch on two days.
Failed to ensure food was palatable and satisfactory for four residents.
Failed to maintain and provide a safe and sanitary shower room for two shower rooms, including water damage, mold, missing tiles, and odors.
Report Facts
Census: 133
Total Capacity: 180
Deficiencies cited: 5
Dates of complaint investigations: 03/06/2022 through 03/11/2022 and follow-up on 03/16/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in physical restraint deficiency and corrective actions |
| Dietary Manager | Dietary Manager (DM) | Named in food handling and palatability deficiencies and corrective actions |
| Maintenance Supervisor | Maintenance Supervisor | Named in shower room maintenance deficiency and corrective actions |
Inspection Report
Annual Inspection
Census: 133
Capacity: 180
Deficiencies: 11
Date: Mar 16, 2022
Visit Reason
The State Survey Agency conducted an annual recertification along with two complaint investigations from 03/06/2022 through 03/11/2022 and a follow-up investigation on 03/16/2022.
Complaint Details
Two complaint investigations were conducted: CI MS #18546 related to medication diversion was substantiated; CI MS #18547 related to palatability of food was substantiated; CI MS #18593 related to abuse was not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with multiple citations including medication diversion, palatability of food, safety, care planning, activities, infection control, and others. Several deficiencies were substantiated related to medication diversion and food palatability.
Deficiencies (11)
Failed to ensure residents had ready and reasonable access to personal funds on weekends for 4 of 32 sampled residents.
Failed to maintain and provide a safe and sanitary shower room and failed to ensure two resident wheelchairs were repaired.
Failed to be free from physical restraints; Resident #101 was in a Geri chair with tray attachment considered a restraint.
Failed to revise care plan after a resident had a fall and failed to identify root cause or implement interventions to prevent reoccurrence.
Failed to implement an ongoing resident-centered activities program that incorporates residents' interests on the memory care unit.
Failed to reassess fall risk, determine root cause of fall, and implement interventions to reduce fall risk for one resident.
Failed to clean suprapubic catheter tubing properly during care, risking urinary tract infection.
Failed to re-evaluate use of psychotropic medication within 14 days and document continued need and duration for one resident.
Failed to ensure food was palatable and satisfactory for four residents; food was bland and unseasoned.
Failed to clean thermometer between food items during tray line temperature testing and failed to record tray line temperatures for breakfast and lunch on two days.
Failed to ensure staff washed or sanitized hands during wound care for one resident.
Report Facts
Deficiencies cited: 10
Residents sampled: 32
Residents on memory care unit: 33
BIMS scores: 15
Fall risk score: 13
PRN psychotropic order duration: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to clean suprapubic catheter tubing and failed to change gloves during wound care. |
| LPN #3 | Licensed Practical Nurse | Provided incomplete fall report for Resident #13. |
| Dietary Manager | Acknowledged food palatability issues and tray line temperature recording lapses. | |
| Director of Nursing | DON | Confirmed multiple deficiencies including restraint use, fall risk management, psychotropic medication re-evaluation, catheter care, and wound care. |
Inspection Report
Routine
Deficiencies: 11
Date: Mar 16, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, safety, care, activities, medication management, food service, and infection control at The Pillars of Biloxi nursing home.
Findings
The facility was found deficient in multiple areas including residents' access to personal funds, maintenance and safety of shower rooms and wheelchairs, use of physical restraints, care plan revisions after falls, resident-centered activities, fall risk management, catheter care, psychotropic medication re-evaluation, food palatability and temperature control, and infection prevention practices.
Deficiencies (11)
Failed to ensure residents had ready and reasonable access to personal funds for four residents.
Failed to maintain and provide a safe and sanitary shower room and failed to ensure two resident wheelchairs were repaired.
Failed to identify the use of a Geri chair with a tray as a physical restraint for one resident.
Failed to revise the care plan after a resident had a fall.
Failed to implement an ongoing resident-centered activities program that incorporates residents' interests on the memory care unit.
Failed to reassess resident fall risk, determine root cause of fall, and implement interventions to reduce fall risk for one resident.
Failed to clean suprapubic catheter tubing properly during care for one resident.
Failed to re-evaluate the use of a psychotropic medication within 14 days for one resident.
Failed to ensure food was palatable and satisfactory for four residents.
Failed to clean thermometer between food items and failed to record tray line temperatures for breakfast and lunch on two days.
Failed to ensure staff washed or sanitized hands during wound care for one resident.
Report Facts
Residents sampled: 32
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in fall incident and care plan revision findings |
| LPN #2 | Licensed Practical Nurse | Named in catheter care and wound care infection control deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple interviews related to fall management, psychotropic medication, and wound care |
| Dietary Manager | Dietary Manager | Named in food palatability and tray line temperature findings |
| Administrator | Administrator | Named in interviews related to resident funds access, activities, and food palatability |
| Business Office Manager | Business Office Manager | Named in resident funds access deficiency |
| LPN #1 | Licensed Practical Nurse | Named in fall incident report and care plan revision findings |
| CNA #5 | Certified Nursing Assistant | Named in fall incident and shower room observations |
| CNA #2 | Certified Nursing Assistant | Named in wheelchair and shower room observations |
| Maintenance Supervisor | Maintenance Supervisor | Named in shower room and maintenance deficiencies |
| LPN #4 | Licensed Practical Nurse | Named in wheelchair and activities deficiencies |
| Activity Aide #3 | Activity Aide | Named in activities program deficiency |
| CNA #3 | Certified Nursing Assistant | Named in fall incident observation |
Inspection Report
Life Safety
Census: 133
Deficiencies: 1
Date: Mar 9, 2022
Visit Reason
The facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider to assess compliance with the 2012 Edition of the Life Safety Code (LSC).
Findings
The facility failed to properly maintain exit egress as per NFPA 101 section 19.2.1 and 7.1.10.1, specifically one of eight exits lacked an all-weather surface to the public way, affecting 18 of 133 residents on the day of survey.
Deficiencies (1)
Exit near Room 401 lacked an all-weather surface (sidewalk) to the public way, making it unusable as a means of egress.
Report Facts
Number of exits affected: 1
Number of residents affected: 18
Census: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged the finding during the exit interview | |
| Maintenance Supervisor | Verified the finding during the exit interview |
Inspection Report
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
Survey conducted to assess compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility meets all applicable Federal, State, and local emergency preparedness requirements as of the survey date.
Inspection Report
Complaint Investigation
Census: 139
Capacity: 180
Deficiencies: 2
Date: Feb 16, 2022
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging inadequate resident care, including insufficient staffing, residents not receiving scheduled baths/showers, and poor nail care.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews. Ombudsmen reported residents being left in soiled briefs, not receiving baths as scheduled, and having long fingernails. The Social Worker confirmed the complaint and the facility developed a plan of correction.
Findings
The facility failed to maintain sufficient staffing levels to meet resident needs, resulting in residents not receiving scheduled baths and showers, and poor nail care. Several residents were observed with long, dirty fingernails and reported delays in care. Staffing ratios were below state standards on multiple days. The facility implemented a plan of correction including increased staffing, education, and audits.
Deficiencies (2)
Failed to maintain sufficient staffing to provide for residents' highest practicable wellbeing, affecting multiple residents.
Failed to provide adequate assistance with activities of daily living including bathing and nail care for multiple residents.
Report Facts
Resident census: 139
Total licensed capacity: 180
Staffing ratio: 2.41
Staffing ratio: 2.3
Staffing ratio: 2.6
Staffing ratio: 2.61
Baths received: 4
Baths received: 8
Baths received: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided nail care to residents and worked double shifts during staffing shortages |
| CNA #1 | Certified Nursing Assistant | Reported working double shifts and staffing shortages affecting resident care |
| CNA #2 | Certified Nursing Assistant | Reported some baths and showers not done due to staffing shortages |
| Director of Nursing | Director of Nursing (DON) | Responsible for nursing services, provided education on nail care and bathing, and involved in staffing reviews |
| Administrator | Facility Administrator | Acknowledged staffing challenges and involved in staffing reviews and plan of correction |
| Social Worker | Social Worker | Confirmed complaints and involved in care plan meetings and plan of correction |
| Activities Director | Activities Director | Explained nail care is provided as an activity only to residents who attend the activities room |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 2
Date: Feb 16, 2022
Visit Reason
The inspection was conducted in response to an anonymous complaint regarding resident care concerns on the 300 unit, including issues with nail care, bathing, and staffing shortages.
Complaint Details
The complaint was anonymous and concerned resident care neglect on the 300 unit, including residents being double briefed and padded, left in saturated briefs, long fingernails, missed baths, and delayed call light responses. The complaint was substantiated by observations and interviews with residents, family members, staff, and ombudsmen.
Findings
The facility failed to provide adequate nail care and bathing for several residents, with observations of long, dirty fingernails and missed showers. Staffing shortages were documented, with insufficient nursing staff on multiple days, leading to delayed or missed care and resident dissatisfaction.
Deficiencies (2)
Failure to keep fingernails trimmed for two residents and failure to provide showers for three residents as scheduled.
Failure to maintain sufficient nursing staff to provide care, resulting in missed baths, delayed responses, and residents left in soiled briefs.
Report Facts
Baths received: 4
Baths received: 8
Baths received: 8
Staffing ratio: 2.41
Staffing ratio: 2.3
Staffing ratio: 2.6
Staffing ratio: 2.61
Days with insufficient staffing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided nail care to residents and worked double shifts due to staffing shortages. |
| CNA #2 | Certified Nursing Assistant | Reported that some baths and showers were not done due to staffing shortages. |
| Director of Nursing | Director of Nursing (DON) | Responsible for audits and education related to nail care, bathing, and staffing. |
| Administrator | Facility Administrator | Acknowledged staffing challenges and implemented corrective actions. |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 180
Deficiencies: 1
Date: Feb 16, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey and Complaint Investigations (CI MS #18475, CI MS #18476, CI MS #18513, CI MS #18488, and CI MS #18487) were conducted by the State Survey Agency from 02/02/2022 through 02/04/2022.
Complaint Details
The SSA substantiated complaint investigation CI #18475 with cited deficiencies for Residents #1, #3, and #4. The SSA did not substantiate complaints CI #18476, CI #18513, CI #18487, and CI #18488.
Findings
The facility was found to be in compliance with infection control regulations and implemented CMS and CDC recommended COVID-19 practices. The SSA substantiated complaint CI #18475 citing deficiencies related to fingernail trimming and shower provision for residents, but did not substantiate the other complaints.
Deficiencies (1)
Facility failed to keep fingernails trimmed and failed to provide showers for residents reviewed for activities of daily living care.
Report Facts
Census: 136
Total licensed capacity: 180
Inspection Report
Complaint Investigation
Census: 136
Capacity: 180
Deficiencies: 1
Date: Feb 16, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey and Complaint Investigations (CI MS #18475, CI MS #18476, CI MS #18513, CI MS #18488, and CI MS #18487) were conducted by the State Survey Agency at the facility from 02/02/2022 through 02/04/2022.
Complaint Details
The SSA substantiated complaint investigation CI #18475 with cited deficiencies F677 and F725 for Residents #1, #3, and #4. Other complaints CI #18476, CI #18513, CI #18487, and CI #18488 were not substantiated.
Findings
The facility was found to be in compliance with infection control regulations and implemented CMS and CDC recommended COVID-19 practices. The SSA substantiated complaint CI #18475 citing deficiencies related to failure to keep fingernails trimmed and failure to provide showers for residents. Other complaints were not substantiated.
Deficiencies (1)
Failure to keep fingernails trimmed and failure to provide showers for residents reviewed for activities of daily living care.
Report Facts
Census: 136
Total licensed capacity: 180
Inspection Report
Complaint Investigation
Census: 136
Capacity: 180
Deficiencies: 2
Date: Feb 16, 2022
Visit Reason
The State Survey Agency conducted multiple complaint investigations from 02/02/22 through 02/16/22 related to allegations of neglect, inadequate care including pressure wounds, infection control, medication administration, feeding assistance, and hygiene concerns.
Complaint Details
Multiple complaints investigated related to neglect, inadequate care including pressure wounds, infection control, medication administration, feeding assistance, and hygiene. None of the complaints were substantiated, but deficiencies were cited related to staffing and care provision.
Findings
The facility was found not in compliance with Minimum Standards of Operation and state licensure requirements, with deficiencies related to insufficient staffing, failure to provide scheduled baths and nail care, and residents being left in soiled briefs. Several residents were observed with long, dirty fingernails and missed showers. Staffing ratios were below state standards on multiple days, especially weekends.
Deficiencies (2)
Failed to maintain sufficient staffing to provide for residents' highest practicable wellbeing for 3 of 5 residents sampled.
Failed to provide assistance with activities of daily living including bathing and nail care for multiple residents.
Report Facts
Resident census: 136
Total licensed capacity: 180
Staffing ratio: 2.8
Staffing ratio observed: 2.3
Baths received: 4
Baths received: 8
Baths received: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Worked double shifts due to staffing shortages; involved in nail care |
| CNA #1 | Certified Nursing Assistant | Worked double shifts due to staffing shortages; reported staffing problems |
| CNA #2 | Certified Nursing Assistant | Reported some baths and showers not done due to staffing shortages |
| Director of Nursing | Director of Nursing (DON) | Responsible for nursing services; acknowledged staffing challenges and nail care practices |
| Administrator | Facility Administrator | Acknowledged staffing challenges and use of agency nurses |
| Social Worker | Facility Social Worker | Confirmed cognitive assessments and reported concerns from Ombudsmen |
| Ombudsman #1 | Ombudsman | Reported anonymous complaints and observations of neglect |
| Ombudsman #2 | Ombudsman | Reported observations of neglect and staffing issues |
| Activities Director | Activities Director | Explained nail care is provided as an activity only to residents who attend |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 180
Deficiencies: 2
Date: Feb 16, 2022
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and multiple complaint investigations related to resident care, including failure to provide adequate nail care, bathing, medication administration, and staffing concerns.
Complaint Details
Multiple complaint investigations (CI #18475, #18476, #18487, #18488, #18513) were conducted. CI #18475 was substantiated with cited deficiencies for failure to provide adequate nail care and bathing. Other complaints related to quality of care, pressure wounds, infection control, medication administration, and neglect were not substantiated.
Findings
The facility was found to be in compliance with infection control regulations but was cited for deficiencies related to failure to keep residents' fingernails trimmed and failure to provide scheduled showers for dependent residents. Staffing shortages were noted, resulting in missed baths and showers and delayed care. Several complaints were substantiated regarding inadequate ADL care, while others were not substantiated.
Deficiencies (2)
Failure to keep fingernails trimmed for residents #3 and #4 and failure to provide showers for residents #1, #3, and #4 as scheduled.
Failure to maintain sufficient nursing staff to provide care for residents on multiple days.
Report Facts
Census: 136
Total Capacity: 180
Baths received: 4
Baths received: 8
Baths received: 8
Staffing ratio: 2.3
Staffing ratio: 2.41
Staffing ratio: 2.6
Staffing ratio: 2.61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided nail care to residents and worked double shifts due to staffing shortages |
| CNA #1 | Certified Nursing Assistant | Worked double shifts due to staffing shortages |
| CNA #2 | Certified Nursing Assistant | Reported some baths and showers were not done due to staffing shortages |
| Director of Nursing | Director of Nursing (DON) | Conducted audits, provided education on nail care and bathing, and reviewed staffing |
| Administrator | Facility Administrator | Notified of complaints, involved in staffing and care plan meetings, and reviewed audits |
| Social Worker | Notified Administrator of complaints and confirmed completion of mental status assessments | |
| Activities Director | Explained nail care activities and limitations | |
| Nurse Consultant | Confirmed staffing ratios were below acceptable standards | |
| Ombudsman #1 | Received anonymous complaints and conducted observations and interviews | |
| Ombudsman #2 | Conducted observations and interviews with Ombudsman #1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey that was conducted on 2021-12-07 to assess the facility's compliance with Minimum Standards of Operation and state licensure requirements.
Complaint Details
The visit was complaint-related, reviewing information from a complaint survey conducted on 2021-12-07. The facility was found to be in compliance and the complaint was effectively resolved.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. The facility was recommended to be placed back in compliance effective 2022-01-20.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey that was conducted on 2021-12-07 to verify corrective measures taken by the facility.
Complaint Details
The visit was related to a complaint survey conducted on 2021-12-07. The desk review confirmed corrective actions were implemented and compliance was restored.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 2022-01-20.
Inspection Report
Complaint Investigation
Census: 141
Capacity: 160
Deficiencies: 0
Date: Jan 19, 2022
Visit Reason
The inspection was conducted as a Complaint Investigation survey from 01/18/2022 to 01/19/2022 for complaint CI MS #18403.
Complaint Details
Complaint Investigation (CI MS #18403) was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated and no deficiencies were cited during this complaint investigation. The facility remains out of compliance for deficiencies cited on 12/07/2021.
Report Facts
Census: 141
Total Capacity: 160
Inspection Report
Complaint Investigation
Census: 141
Capacity: 160
Deficiencies: 0
Date: Jan 19, 2022
Visit Reason
The State Survey Agency conducted a complaint investigation survey at the facility from 01/18/2022 to 01/19/2022 for complaint investigation #MS18403.
Complaint Details
Complaint investigation #MS18403 was not substantiated due to lack of evidence of negligence regarding medication administration, resident grooming, pressure sore precautions, and facility staffing.
Findings
The complaint investigation was not substantiated due to lack of evidence of negligence related to quality of care, medication administration, grooming, pressure sore precautions, and staffing. No deficiencies were cited during this investigation, though the facility remains out of compliance for prior deficiencies cited on 12/07/2021.
Report Facts
Census: 141
Total licensed capacity: 160
Inspection Report
Complaint Investigation
Census: 143
Capacity: 180
Deficiencies: 0
Date: Dec 7, 2021
Visit Reason
The State Agency conducted a complaint survey at the facility from 11/29/2021 through 12/7/2021.
Complaint Details
Complaint survey MS #1839, MS #18320, MS #18323, MS #18324, MS #18332, and MS #18334 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Residents present: 143
Licensed capacity: 180
Inspection Report
Complaint Investigation
Census: 143
Capacity: 180
Deficiencies: 2
Date: Dec 7, 2021
Visit Reason
The State Agency conducted a complaint survey from 11/29/2021 to 12/7/2021 based on multiple complaint investigations regarding insufficient supplies, quality of care, infection control, physical environment, resident abuse and neglect, and medication storage.
Complaint Details
Multiple complaints investigated (MS #18322, MS #18334, MS #18319, MS #18320, MS #18323, MS #18324). MS #18319 substantiated for insufficient supplies and equipment maintenance. Other complaints related to quality of care, infection control, physical environment, resident abuse, and neglect were unsubstantiated or not substantiated due to insufficient evidence.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with substantiated deficiencies related to insufficient mechanical lift slings and equipment maintenance, and improper drug storage. Mechanical lift batteries were often not charged, causing delays in resident transfers. Several complaints were unsubstantiated due to insufficient evidence.
Deficiencies (2)
Failed to provide safe, secure storage of medications in one medication room; medication room door was propped open and medications were improperly stored.
Failed to maintain mechanical lift batteries adequately charged for safe operation, causing delays in resident transfers.
Report Facts
Residents present: 143
Licensed beds: 180
Medication rooms observed: 4
Medication room door propped open duration: 20
Transfer delay duration: 23
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in medication storage and mechanical lift battery deficiencies; responsible for education and audits |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Observed passing medication room door propped open without noticing |
| Certified Nurse Aide #4 | Certified Nurse Aide (CNA) | Described mechanical lift battery charging procedures and involved in resident transfer with battery failure |
| Certified Nurse Aide #5 | Central Supply Clerk | Responsible for ordering and stocking over-the-counter medications |
| Certified Nurse Aide #6 | Certified Nurse Aide (CNA) | Reported residents sometimes had to wait due to uncharged mechanical lift batteries |
| Certified Nurse Aide #7 | Certified Nurse Aide (CNA) | Reported residents sometimes had to wait due to uncharged mechanical lift batteries |
Inspection Report
Annual Inspection
Census: 116
Capacity: 140
Deficiencies: 0
Date: Nov 30, 2021
Visit Reason
The State Agency conducted a post-certification revisit for an Annual Re-Certification Survey at the facility on 11/29/2021 through 11/30/2021.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements related to care plan revision, supervision and accidents, transfer/discharge notification, Minimum Data Set discharge assessment, dietary, and Quality Assurance Program. No deficiencies were cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 15, 2021
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey conducted on 2021-10-01 to verify corrective measures taken by the facility.
Complaint Details
The visit was complaint-related, and the facility was found to have corrected the deficiencies identified in the complaint survey.
Findings
The facility had implemented measures to correct the deficient practice and was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm as of 2021-11-12.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 15, 2021
Visit Reason
The State Agency conducted a desk review related to a complaint survey that was conducted on 2021-10-01.
Complaint Details
The visit was complaint-related, confirming corrective measures were implemented following the complaint survey on 2021-10-01.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 2021-11-12.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
The State Agency conducted two complaint investigations (MS #18243 and MS #18256) from 11/3/21 through 11/4/21 to investigate allegations against the facility.
Complaint Details
Two complaint investigations (MS #18243 and MS #18256) were conducted and were not substantiated.
Findings
The complaints were not substantiated, and the facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Inspection Report
Complaint Investigation
Census: 139
Capacity: 180
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
The State Agency conducted two complaint investigations at the facility from 11/3/21 through 11/4/21 related to Quality of Care/falls, Quality of Care/pressure sores, Quality of Care/weight, and Abuse/verbal.
Complaint Details
Two complaint investigations were conducted (CI MS #18256 and CI MS #18243) concerning quality of care and abuse allegations; both complaints were not substantiated.
Findings
During the survey, the State Agency did not substantiate the complaints.
Report Facts
Licensed beds: 180
Resident census: 139
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2021
Visit Reason
The State Agency conducted two complaint investigations (MS #18120 and MS #18131) from 2021-09-29 through 2021-10-01. The investigation was triggered by complaints regarding resident rights and dignity.
Complaint Details
Two complaint investigations were conducted. MS #18120 was substantiated with a cited deficiency related to residents' rights and dignity. MS #18131 was not substantiated.
Findings
The facility was found not in compliance with Minimum Standards of Operation and state licensure requirements. Specifically, the facility failed to ensure dignity during clothing change for one resident, who was changed in an activity room without privacy. The complaint MS #18120 was substantiated and cited, while MS #18131 was not substantiated.
Deficiencies (1)
Failure to ensure dignity during clothing change for one resident, who was changed in an activity room without privacy.
Report Facts
Complaint investigations conducted: 2
Resident involved: 1
Resident cognitive score: 13
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 1
Date: Oct 1, 2021
Visit Reason
The State Agency conducted a complaint survey from 9/29/21 through 10/1/21 related to Resident Rights/Resident Verbal Abuse and Neglect/pressure sores and medications, Quality of Care issues, and Physical Environment concerns.
Complaint Details
Complaint survey was conducted for MS #18120 regarding Resident Rights/Resident Verbal Abuse which was substantiated, and MS #18131 regarding Neglect/pressure sores and medications which was not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. One complaint (MS #18120) was substantiated related to violation of resident privacy during clothing change, while another complaint (MS #18131) was not substantiated.
Deficiencies (1)
Facility failed to ensure dignity during clothing change for one resident by changing clothes in an activity room without privacy.
Report Facts
Licensed beds: 180
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Named in deficiency for assisting Resident #1 to change clothes in an area lacking privacy | |
| License Practical Nurse (LPN) #1 | Witnessed CNA #2 assisting Resident #1 during clothing change | |
| Housekeeping #1 | Observed CNA #2 assisting Resident #1 during clothing change | |
| Administrator | Interviewed regarding clothing change practice and resident rights | |
| Social Services Director | Conducted resident interviews and observational rounds as part of corrective action |
Inspection Report
Deficiencies: 0
Date: May 11, 2021
Visit Reason
A desk review was conducted on 5/11/21 to assess the facility's compliance status.
Findings
The facility was found to be in substantial compliance as of 4/25/21 with no deficiencies cited in this review.
Inspection Report
Complaint Investigation
Census: 143
Capacity: 180
Deficiencies: 1
Date: Apr 1, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI MS #17687) at the facility on 4/1/21 due to an alleged physical abuse incident involving Resident #4.
Complaint Details
The complaint investigation was triggered by an allegation that CNA #1 physically abused Resident #4 by slapping him. The allegation was not substantiated for physical abuse, but the facility cited a deficiency for failure to report the alleged abuse timely. CNA #2 witnessed the abuse but did not report it to the facility, instead reporting it to the District Ombudsman the next day. The Administrator failed to report the incident to the State Agency within two hours because the employee did not report it to the facility.
Findings
The investigation found that the facility failed to report alleged physical abuse in a timely manner as required. CNA #2 witnessed CNA #1 slap Resident #4 but failed to report the incident to facility officials within the required timeframe. The allegation of abuse was ultimately unsubstantiated, but CNA #2 was terminated for failure to report.
Deficiencies (1)
Failure to report alleged physical abuse within two hours of the alleged event as required by regulation.
Report Facts
Facility licensed capacity: 180
Census: 143
Dates of in-service training: CNA #2 signed abuse prevention policy on 2/24/21 and attended in-service on 3/15/21
Date of alleged abuse incident: 3/28/21 at 06:00 AM
Date of investigation completion: 4/1/21
Date CNA #2 terminated: 4/1/21
Date CNA #1 suspended: 3/29/21 pending investigation
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Failed to report alleged abuse witnessed on 3/28/21; terminated for failure to report |
| CNA #1 | Certified Nursing Assistant | Alleged to have slapped Resident #4; suspended pending investigation |
| Administrator | Failed to report alleged abuse to State Agency within two hours due to employee failure to report | |
| LPN #1 | Licensed Practical Nurse | Interviewed; unaware of abuse allegations |
| LPN #2 | Licensed Practical Nurse, Day Shift Charge Nurse | Interviewed; unaware of abuse allegations |
| Social Service Director | Conducted resident interviews and staff interviews regarding abuse policy |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 1, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI MS#17687) regarding an allegation of physical abuse at the facility.
Complaint Details
Complaint investigation for physical abuse was conducted and not substantiated.
Findings
The complaint was not substantiated, and the facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 24, 2021
Visit Reason
A desk review was conducted on 3/24/21 to assess the facility's compliance status.
Findings
The facility was found to be in substantial compliance as of 3/18/21.
Inspection Report
Deficiencies: 0
Date: Mar 24, 2021
Visit Reason
A desk review was conducted on 3/24/21 to assess the facility's compliance status.
Findings
The facility was found to be in substantial compliance as of 3/18/21.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 18, 2021
Visit Reason
The inspection was conducted as a complaint investigation (CI MS #17466, CI MS #17561) from 02/17/21 to 02/18/21 due to allegations of noncompliance with Minimum Standards of Operation for Institutions for the Aged or Infirm state licensure requirements.
Complaint Details
The complaint investigation found the facility was not in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm state licensure requirements related to incontinent care and wound care procedures. The complaint was substantiated with evidence from observation, interviews, and record review.
Findings
The facility failed to perform incontinent care before and during wound care for Resident #3, resulting in a violation of infection control precautions and potential spread of infection. The wound care nurse did not clean the resident prior to wound care despite the resident being soiled with feces, which was confirmed by multiple staff interviews and policy review.
Deficiencies (1)
Failed to follow Standard Infection Control Precautions related to performing incontinent care prior and/or during wound care to prevent possible spread of infection for one of three wound care observations (Resident #3).
Report Facts
Wound care observations: 3
Residents with pressure sores assessed: 14
BIMS score: 9
Dates of complaint investigation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Performed wound care on Resident #3 without providing incontinent care prior and during wound care |
| Registered Nurse #2 | Infection Preventionist | Confirmed RN #1 should have stopped wound care and provided incontinent care for Resident #3 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed Resident #3 and educated RN #1 on wound care and infection control |
| Director of Nurses | Director of Nurses (DON) | Confirmed wound care nurse should have followed infection control policy and cleaned Resident #3 prior to wound care |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 180
Deficiencies: 2
Date: Feb 18, 2021
Visit Reason
The State Agency conducted a complaint investigation from 02/17/21 through 02/18/21 related to allegations including failure to clean scissors used in wound care and failure to perform incontinent care before and during wound care.
Complaint Details
The complaint investigation included two complaint IDs: CI MS #17466 and CI MS #17561. CI MS #17561 was substantiated for failure to clean scissors used in wound care and failure to perform incontinent care. CI MS #17466 was not substantiated for failure to give medications per Professional Standards.
Findings
The facility was substantiated for failure to clean reusable medical equipment (scissors) before and after wound care for two residents, and failure to perform incontinent care before and during wound care for one resident, potentially causing infection risks. No adverse outcomes were noted for assessed residents following corrective actions.
Deficiencies (2)
Failure to perform incontinent care before and during wound care for Resident #3, leading to potential infection risk.
Failure to clean and disinfect reusable medical equipment (scissors) before and after wound care for Resident #1 and Resident #3.
Report Facts
Licensed beds: 180
Resident census: 136
Residents with pressure sores assessed: 14
Wound care observations by ADON: 2
Wound care observation period: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in findings for failure to clean scissors and perform incontinent care during wound care |
| Registered Nurse #2 | Infection Preventionist | Interviewed regarding wound care concerns and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Performed resident assessments, educated RN #1, and responsible for wound care observations |
| Director of Nurses | Director of Nurses (DON) | Interviewed confirming infection control policies and deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
The inspection was conducted as a result of nine complaint investigations dated from 2021-01-14 to 2021-01-20, to determine compliance with state licensure requirements and minimum standards of operation for institutions for the aged or infirm.
Complaint Details
Nine complaint investigations (CI MS #16805, #16820, #16945, #17270, #17299, #17369, #17400, #17444, #17445) were conducted covering allegations including abuse, neglect, quality of care, resident rights, responsible party notification, call bell response, facility staffing, medication, pharmaceutical services, and misappropriation of property. All investigations were unsubstantiated with no deficiencies cited.
Findings
All nine complaint investigations were unsubstantiated with no deficiencies cited. The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements, as well as Medicare and Medicaid participation requirements where applicable.
Report Facts
Number of complaint investigations: 9
Inspection Report
Complaint Investigation
Census: 137
Capacity: 180
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and nine complaint investigations were conducted by the State Agency from 2021-01-14 through 2021-01-20, with an extension through 2021-02-02.
Complaint Details
Nine complaint investigations (CI MS #16805, #16820, #16945, #17270, #17299, #17369, #17400, #17444, #17445) were conducted and all were unsubstantiated with no deficiencies cited. Complaints included allegations related to abuse, neglect, quality of care, resident rights, staffing, medication, and misappropriation of property.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended COVID-19 practices. All nine complaint investigations were unsubstantiated with no deficiencies cited, and the facility was determined to be in compliance with Medicare and Medicaid requirements.
Report Facts
Number of complaint investigations: 9
Census: 137
Total licensed capacity: 180
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 2021-01-14 through 2021-01-20, extended through 2021-02-01 to 2021-02-02.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 2021-01-14 through 2021-01-20, with an extension from 2021-02-01 through 2021-02-02.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
The inspection was conducted as a result of nine complaint investigations occurring between 01/14/2021 and 01/20/2021.
Complaint Details
Nine complaint investigations (CI MS #16805, #16820, #16945, #17270, #17299, #17369, #17400, #17444, #17445) were conducted. All were unsubstantiated with no deficiencies cited, covering issues such as abuse, neglect, quality of care, resident rights, responsible party notification, call bell response, facility staffing, pharmaceutical services, and misappropriation of property.
Findings
All nine complaint investigations were unsubstantiated with no deficiencies cited. The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Report Facts
Number of complaint investigations: 9
Inspection Report
Routine
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 2021-01-14 through 2021-01-20, with an extension through 2021-02-02.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Routine
Census: 149
Capacity: 180
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Census: 149
Capacity: 180
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/27/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Abbreviated Survey
Census: 157
Capacity: 180
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 153
Capacity: 180
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 153
Total licensed capacity: 180
Inspection Report
Routine
Census: 153
Capacity: 180
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 153
Total licensed capacity: 180
Inspection Report
Complaint Investigation
Census: 128
Capacity: 180
Deficiencies: 1
Date: Feb 19, 2020
Visit Reason
The State Agency conducted a complaint survey from 02/17/2020 to 02/19/2020 based on complaints MS #16599 and MS #16612. The survey was triggered by allegations related to Quality of Care, Misappropriation of Property, and Physical Environment.
Complaint Details
The complaint investigation was substantiated for Quality of Care related to supervision of residents. The facility failed to prevent Resident #1 from eloping through a window on 02/02/2020. Resident #1 was found by local ambulance service and returned to the facility with no injury. The facility implemented visual monitoring and one-on-one supervision after the incident. The complaint MS #16599 related to Quality of Care, Misappropriation of Property, and Physical Environment was not substantiated.
Findings
The facility was found not in compliance with Minimum Standards of Operation. The complaint MS #16612 was substantiated for Quality of Care related to inadequate supervision of residents, specifically failure to prevent a resident from leaving the facility unsupervised. The complaint MS #16599 was not substantiated and no deficiencies were cited for those allegations.
Deficiencies (1)
Failed to provide adequate supervision to prevent a resident from leaving the facility unsupervised, for one of four residents reviewed for risk of wandering/elopement.
Report Facts
Residents at risk for elopement: 57
Census: 128
Total licensed capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | RN | Discovered Resident #1 missing during medication pass and participated in search. |
| Licensed Practical Nurse #1 | LPN | Communicated with local ambulance service and assisted in identifying Resident #1 at a local store. |
| Licensed Practical Nurse #2 | LPN | Interviewed Resident #1 about elopement and spoke with Resident Representative. |
| Certified Nursing Assistant #1 | CNA | Observed Resident #1 in bed early morning and assisted in search after he was found missing. |
| Certified Nursing Assistant #2 | CNA | Assisted in search for Resident #1 after he was reported missing. |
| Administrator | Facility Administrator | Interviewed regarding the incident, described the circumstances of Resident #1's elopement and facility response. |
| Director of Nursing | DON | Reported Resident #1 missing to Administrator and involved in facility response. |
| Assistant Director of Nursing | ADON | Placed residents at risk for elopement on visual monitoring and conducted staff in-service training. |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 180
Deficiencies: 1
Date: Feb 19, 2020
Visit Reason
The State Agency conducted a complaint survey at the facility from 02/17/2020 to 02/19/2020, triggered by complaints MS #16599 and MS #16612. The survey was to investigate compliance with Medicare and Medicaid participation requirements, specifically focusing on Quality of Care related to supervision of residents and other issues.
Complaint Details
The complaint survey was substantiated for Quality of Care related to supervision of residents (MS #16612). The complaint regarding Quality of Care, Misappropriation of Property, and Physical Environment (MS #16599) was not substantiated and no deficiencies were cited for that complaint.
Findings
The facility was found not in compliance due to failure to provide adequate supervision to prevent a resident at risk for wandering/elopement from leaving the facility unsupervised. Resident #1 left the facility through a window and was found by local ambulance service. The facility lacked sufficient interventions to prevent this incident, despite policies and assessments in place. The facility implemented corrective actions including visual monitoring and staff in-service training.
Deficiencies (1)
Failure to provide adequate supervision to prevent a resident from leaving the facility unsupervised, specifically a resident at risk for wandering/elopement.
Report Facts
Residents at risk for elopement: 57
Census: 128
Total licensed capacity: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Discovered Resident #1 missing during medication pass and involved in search and communication with ambulance service. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Communicated with ambulance service and staff regarding missing Resident #1. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed Resident #1 about elopement and communicated with Resident Representative. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed Resident #1 in bed early morning and participated in search after Resident #1 was found missing. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Assisted with search for Resident #1 after he was reported missing. |
| Administrator | Facility Administrator | Provided multiple interviews detailing the incident, investigation, and corrective actions. |
| Director of Nursing | Director of Nursing | Reported the incident and involved in staff in-service and corrective actions. |
| Assistant Director of Nursing | Assistant Director of Nursing | Placed residents at risk on visual monitoring and involved in staff in-service. |
| Minimum Data Set Coordinator | MDS Coordinator | Revised care plans for residents at risk and responsible for audits and reporting to Quality Assurance Committee. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 5
Date: Jan 24, 2020
Visit Reason
The State Agency conducted a Complaint Investigation from 01/21/2020 to 01/24/2020 related to a staff member verbally abusing a resident.
Complaint Details
The complaint was substantiated for verbal abuse involving Certified Nursing Assistant #1 verbally abusing Resident #1 with curse words. The facility failed to protect the resident and report the abuse timely to the State agencies.
Findings
The facility was found not in compliance with requirements related to freedom from abuse and neglect, with an Immediate Jeopardy and Substandard Quality of Care identified due to verbal abuse by a Certified Nursing Assistant toward a resident. The facility failed to protect the resident and report the abuse timely to appropriate agencies.
Deficiencies (5)
Failure to protect residents from verbal abuse and failure to report abuse within two hours to State agencies.
Failure to develop and implement abuse/neglect policies to protect residents and report allegations timely.
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment within two hours.
Failure to thoroughly investigate witnessed staff verbal abuse and failure to protect residents.
Failure to protect residents from verbal abuse and failure to report incidents timely to appropriate agencies.
Report Facts
Facility licensed beds: 180
Resident census: 140
Number of residents reviewed for abuse: 7
Number of employees interviewed: 5
Number of residents interviewed: 5
Number of times Resident #1 was seen by CNA #1 after incident: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in verbal abuse finding and failure to protect residents. |
| Licensed Practical Nurse #1 | LPN | Reported the incident and was involved in investigation. |
| Licensed Practical Nurse #2 | LPN | Reported the incident and instructed CNA #1 reassignment. |
| Dietary Manager | Witnessed the verbal abuse incident and reported findings. | |
| Director of Nursing | DON | Involved in investigation and failure to protect residents. |
| Administrator | Notified of IJ and SQC, involved in investigation and reporting. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 7
Date: Jan 24, 2020
Visit Reason
The State Agency conducted a Complaint Investigation from 01/21/2020 to 01/24/2020 related to a staff member verbally abusing a resident.
Complaint Details
The complaint was substantiated for verbal abuse by Certified Nursing Assistant #1 toward Resident #1. The abuse involved use of curse words and threats witnessed by staff and residents. The facility failed to protect the resident and report the abuse timely to the State designated agencies.
Findings
The facility was found not in compliance with requirements related to freedom from abuse and neglect, with an Immediate Jeopardy and Substandard Quality of Care cited for verbal abuse by a Certified Nursing Assistant toward a resident. The facility failed to protect the resident and report the abuse timely to appropriate agencies. A credible Removal Plan was accepted and the Immediate Jeopardy was removed on 01/24/2020.
Deficiencies (7)
Failure to protect residents from verbal abuse by a staff member and failure to report the abuse within two hours to the State designated agencies.
Failure to develop and implement abuse/neglect policies to protect residents from verbal abuse and to report allegations timely.
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment within two hours of the allegation.
Failure to thoroughly investigate witnessed verbal abuse and failure to protect residents from further abuse.
Failure to protect residents from verbal abuse and failure to report incidents of witnessed verbal abuse timely.
Failure to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately and investigated thoroughly.
Failure to protect residents from verbal abuse and failure to report incidents timely to appropriate agencies.
Report Facts
Licensed beds: 180
Census: 140
Deficiency count: 7
Immediate Jeopardy removal date: Jan 24, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in verbal abuse finding toward Resident #1 |
| Director of Nursing | DON | Involved in failure to protect and report abuse |
| Dietary Manager | Witnessed verbal abuse incident between CNA #1 and Resident #1 | |
| Licensed Practical Nurse #1 | LPN | Reported verbal abuse incident and involved in investigation |
| Licensed Practical Nurse #2 | LPN | Reported incident to DON and involved in investigation |
| Social Worker | SW | Interviewed residents and employees regarding abuse |
| Psychiatric Nurse Practitioner | Assessed Resident #1 with no adverse findings | |
| Administrator | Notified of abuse, reviewed personnel files, and involved in corrective actions |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 180
Deficiencies: 4
Date: Jan 24, 2020
Visit Reason
Complaint Investigation MS #16522 was conducted from 01/21/2020 to 01/24/2020 due to substantiated verbal abuse allegations involving CNA #1 and Resident #1.
Complaint Details
Complaint MS #16522 was substantiated for verbal abuse involving CNA #1 verbally abusing Resident #1 on 12/21/2019. The facility failed to protect the resident and report the abuse timely, resulting in Immediate Jeopardy status.
Findings
The facility failed to protect Resident #1 from verbal abuse by CNA #1 on 12/21/2019, allowed CNA #1 to continue working without suspension, and failed to report the abuse to State Agencies within two hours. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care. The facility implemented corrective actions including staff training, resident assessments, and reporting improvements, and the Immediate Jeopardy was removed on 01/24/2020.
Deficiencies (4)
Failure to ensure a resident was free from verbal abuse by staff and failure to protect residents from verbal abuse.
Failure to develop and implement abuse/neglect policies including timely reporting and protection of residents.
Failure to report alleged violations involving abuse within required timeframes.
Failure to investigate, prevent, and correct alleged violations and failure to prevent further potential abuse during investigation.
Report Facts
Facility licensed capacity: 180
Facility census: 140
Dates CNA #1 worked post-incident: 3
Resident assessments: 100
Staff in-service training completion: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal abuse incident and failure to protect residents |
| LPN #1 | Licensed Practical Nurse | Reported verbal abuse incident to on-call nurse |
| LPN #2 | Licensed Practical Nurse (on-call nurse) | Received report of verbal abuse and instructed reassignment of CNA #1 |
| Director of Nursing | Director of Nursing (DON) | Informed of verbal abuse incident and failed to suspend CNA #1 immediately |
| Administrator | Facility Administrator | Responsible for reporting abuse and overseeing corrective actions |
| Dietary Manager | Dietary Manager | Witnessed verbal abuse incident in dining room |
| CNA #2 | Certified Nursing Assistant | Witnessed verbal abuse incident |
| CNA #3 | Certified Nursing Assistant | Witnessed verbal abuse incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation at the facility.
Complaint Details
Complaint investigation was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 27, 2019
Visit Reason
A complaint investigation was conducted at the facility.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 111
Capacity: 180
Deficiencies: 1
Date: Jun 12, 2019
Visit Reason
The State Agency conducted a complaint survey from 06/10/19 to 06/12/19 at The Pillars of Biloxi related to complaints CI MS #15935 and #15958.
Complaint Details
The complaint survey was conducted for CI MS #15935 and #15958. The SA substantiated CI MS #15935 with deficiencies and cited state statute M700. CI MS #15958 was substantiated with no deficiencies.
Findings
The survey substantiated two of five concerns regarding quality of care for CI MS #15935 and cited deficiency F755 related to pharmacy services and medication procedures. No deficiencies were cited for CI MS #15958. The facility failed to obtain medications ordered for Resident #4 on admission.
Deficiencies (1)
The facility failed to obtain medications ordered for Resident #4 on admission, including issues with ordering, receiving, and documenting controlled drugs and other medications.
Report Facts
Residents reviewed: 4
Census: 111
Total licensed beds: 180
Dates of survey: From 2019-06-10 to 2019-06-12.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Reviewed all residents' medication orders and verified receipt from pharmacy. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication delivery and pharmacy issues for Resident #4. |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 180
Deficiencies: 1
Date: Jun 12, 2019
Visit Reason
The State Agency conducted a complaint survey from 06/10/19 to 06/12/19 at The Pillars of Biloxi related to complaints CI MS #15935 and #15958.
Complaint Details
The complaint survey was conducted for CI MS #15935 and #15958. The SA substantiated complaint #15935 with deficiencies cited, and substantiated complaint #15958 with no deficiencies cited.
Findings
The survey substantiated two of five concerns regarding quality of care for complaint #15935 and cited deficiency F755 related to pharmacy services and medication management. No deficiencies were cited for complaint #15958.
Deficiencies (1)
The facility failed to obtain medications ordered for Resident #4 on admission, including issues with ordering, receipt, and administration of multiple medications.
Report Facts
Residents reviewed: 4
Licensed beds: 180
Census: 111
Dates of survey: 06/10/19 to 06/12/19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reviewed all residents' medication orders and verified receipt from pharmacy |
| Director of Nursing | Director of Nursing | Interviewed regarding medication delivery and administration for Resident #4 |
| Resident #4's Responsible Party | Interviewed regarding medication possession and administration upon admission |
Inspection Report
Renewal
Deficiencies: 0
Date: May 16, 2019
Visit Reason
A standard recertification survey was conducted by Healthcare Management Solutions on behalf of the MS State Department of Health from 5/12/19 through 5/16/19. In addition, Complaint Intake Number MS15878 was investigated in conjunction with the standard survey.
Complaint Details
Complaint Intake Number MS15878 was investigated but was not substantiated for Quality of Care and Treatment.
Findings
The complaint was not substantiated for Quality of Care and Treatment and resulted in no citations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Mullins | Administrator | Signed the report as Administrator on 6/20/2019 |
Inspection Report
Renewal
Deficiencies: 0
Date: May 16, 2019
Visit Reason
A standard recertification survey was conducted by Healthcare Management Solutions on behalf of the MS State Department of Health from 5/12/19 through 5/16/19. In addition, Complaint Intake Number MS15878 was investigated in conjunction with the standard survey.
Complaint Details
Complaint Intake Number MS15878 was investigated but was not substantiated for Quality of Care and Treatment.
Findings
The complaint was not substantiated for Quality of Care and Treatment and resulted in no citations.
Report Facts
Survey dates: Survey conducted from 2019-05-12 through 2019-05-16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Mullins | Administrator | Signed the report |
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