Inspection Reports for Tunica Nursing Home
1024 Highway 61 South, Tunica, MS 38676, MS, 38676
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 7
Oct 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, food safety, and therapy services at Tunica County Health & Rehab, LLC.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment due to leaking air-conditioning units, inaccurate coding of resident assessments, incomplete care plans for residents' needs, inadequate fingernail care, failure to prevent contractures due to lack of timely therapy and ROM exercises, unsanitary food preparation and storage practices, and delayed provision of specialized rehabilitative services.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Actual harm: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, comfortable, and homelike environment by not repairing or reporting leaking air-conditioning units in two resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately code a Minimum Data Set (MDS) for one resident assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop comprehensive person-centered care plans addressing identified care needs for two residents. | Level of Harm - Actual harm |
| Failure to provide fingernail care for one resident, placing the resident at risk for skin injury and infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care to maintain or improve range of motion, resulting in contracture for one resident. | Level of Harm - Actual harm |
| Failure to ensure food was prepared and served under sanitary conditions and failure to label and store food properly in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure timely provision of therapy services, resulting in delayed evaluation and treatment contributing to worsening contracture for one resident. | Level of Harm - Actual harm |
Report Facts
Residents reviewed for care planning: 53
Residents reviewed for activities of daily living: 53
Residents reviewed for range of motion: 3
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Residents affected by deficiencies: Few
Residents affected by deficiencies: Few
Residents affected by deficiencies: Few
Residents affected by deficiencies: Few
Residents affected by deficiencies: Many
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Licensed Practical Nurse | Verified leaking AC unit and lack of maintenance notification |
| Certified Nursing Assistant (CNA #1) | Certified Nursing Assistant | Verified leaking AC unit and sheets placed under AC |
| Director of Nursing | Director of Nursing | Provided expectations on maintenance notification and care standards |
| MDS Nurse | MDS Nurse | Confirmed inaccurate MDS coding and care plan deficiencies |
| Licensed Practical Nurse (LPN #1) | Licensed Practical Nurse | Confirmed fingernail care deficiency |
| Director of Nursing (DON) | Director of Nursing | Confirmed fingernail care expectations and risks |
| Rehabilitation Director (RD) | Rehabilitation Director | Confirmed lack of restorative program and delayed therapy evaluation |
| Administrator | Administrator | Confirmed expectations for therapy evaluations and food safety compliance |
| Dietary Aide #1 | Dietary Aide | Confirmed lack of hair nets and food safety violations |
| Dietary Manager (DM) | Dietary Manager | Confirmed food storage and labeling deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 4, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident injury caused by failure to follow the resident's care plan for transfers, specifically the improper use of a total mechanical lift.
Findings
The facility failed to implement a person-centered care plan for one resident requiring total mechanical lift transfers, resulting in a right tibia fracture after a CNA transferred the resident manually. The investigation confirmed the CNA did not follow the care plan, leading to injury. Corrective actions including staff inservices, audits, and ongoing observations were implemented and validated by the State Agency.
Complaint Details
The complaint investigation was substantiated. The CNA transferred Resident #1 without using the required total lift and without assistance, causing a right tibia fracture. The CNA admitted to the improper transfer and was suspended and terminated. The facility notified the resident's representative, physician, State Agency, and Attorney General. Corrective actions were implemented and validated prior to the State Agency's entrance.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement a complete care plan that meets all the resident's needs, resulting in actual harm due to improper transfer. | Level of Harm - Actual harm |
| Failure to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident's right tibia fracture. | Level of Harm - Actual harm |
Report Facts
Residents reviewed: 3
Residents affected: 1
CNA lift observation frequency: 2
Observation days per week: 5
Observation weeks: 3
Additional observation days per week: 2
Additional observation weeks: 3
BIMS score: 13
Tylenol dosage: 650
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Assistant | Admitted to transferring resident without using total lift, resulting in injury; suspended and terminated |
| LPN #1 | Licensed Practical Nurse | Evaluated resident post-incident and administered pain medication |
| LPTA | Licensed Physical Therapy Assistant | Evaluated resident's knee swelling and pain, notified DON |
| DON | Director of Nursing | Verified investigation findings, participated in QA meeting, and confirmed corrective actions |
| ADM | Administrator | Verified investigation findings, participated in QA meeting, confirmed CNA termination and corrective actions |
| OTS | Occupational Therapy Student | Noted resident's knee swelling and pain during therapy session and reported findings |
Inspection Report
Deficiencies: 5
Jun 19, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, accident prevention, dialysis care, and food safety at Tunica County Health & Rehab, LLC.
Findings
The facility failed to notify the medical provider and dialysis clinic about a resident's continued refusal of medications, failed to implement a fall risk care plan requiring two staff for mechanical lifts, failed to prevent accident hazards during resident transfers, and failed to maintain cleanliness of a resident's personal refrigerator, posing risks to resident health and safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify the provider of a change in a resident's status when a resident refused medications two or more consecutive times (Resident #46). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a fall risk care plan requiring two staff assists for mechanical lift transfers (Resident #1). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nursing home area was free from accident hazards and provide adequate supervision during mechanical lift transfers requiring two staff (Resident #1). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to communicate pertinent resident information to contracted dialysis facility regarding medication refusals (Resident #46). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain cleanliness of a resident's personal refrigerator, resulting in mildew and potential foodborne illness risk (Resident #8). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Refused medication doses: 6
Refused medication doses: 12
Refused medication doses: 5
Refused medication doses: 5
Refused medication doses: 5
Refused medication doses: 5
Refused medication doses: 5
Refused medication doses: 5
Refused medication doses: 5
Refused medication doses: 4
Refused medication doses: 10
Refused medication doses: 22
Refused medication doses: 22
Refused medication doses: 20
Residents care plans reviewed: 16
Residents reviewed for accidents and hazards: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Aware of Resident #46 medication refusals but did not notify medical provider or dialysis |
| Director of Nursing | Director of Nursing | Confirmed failure to notify medical provider and dialysis of Resident #46 medication refusals and confirmed fall risk care plan requirements |
| Certified Nurse's Assistant #2 | Certified Nurse's Assistant | Did not use two staff to transfer Resident #1 as required |
| Certified Nurse's Assistant #3 | Certified Nurse's Assistant | Confirmed two staff required for mechanical lift transfers |
| Dialysis Registered Nurse #1 | Dialysis Registered Nurse | Unaware of Resident #46 medication refusals and stated she would notify provider and care team |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Identified mildew in Resident #8's refrigerator and confirmed it was not cleaned recently |
| Infection Preventionist | Infection Preventionist | Did not check cleaning of resident refrigerators and unable to confirm last cleaning date |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 27, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a Resident Representative of a change in status of a resident resulting in hospitalization.
Findings
The facility failed to notify the Resident Representative of Resident #1's change in mental status and subsequent hospitalization. The Director of Nursing attempted to notify the representative but did not document continued attempts, and staff did not follow up to ensure notification was completed.
Complaint Details
The complaint investigation found that the facility did not properly notify the Resident Representative of Resident #1's hospitalization and change in mental status. The Director of Nursing admitted to not following up after an initial unsuccessful contact attempt, and nursing staff were unaware of the need to continue notification attempts.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify a Resident Representative of a change in status of a resident resulting in hospitalization for one of three residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed with changes in mental/physical condition: 3
Residents affected: 1
Date of resident admission: Jan 6, 2023
Date of resident transfer: Dec 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Attempted notification of Resident Representative but failed to follow up |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Nurse for Resident #1 on 12/5/23, unaware that notification was incomplete |
| Administrator | Administrator | Confirmed lack of documentation and follow-up attempts to notify Resident Representative |
Inspection Report
Routine
Deficiencies: 2
Mar 29, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights regarding food preferences and to evaluate the sanitation and maintenance of the facility's ice machine.
Findings
The facility failed to honor the food preferences of one resident by repeatedly serving foods the resident had requested not to have. Additionally, the facility failed to properly clean the only functioning ice machine, which had visible black mold spots, potentially exposing residents and staff to gastrointestinal upset.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to honor food preferences for one resident by serving sausage and cereal despite documented requests not to serve these items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to clean the ice machine that served residents and staff, evidenced by five spots of black substance (likely mold) on the ice. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for food preferences: 15
Spots of black substance on ice: 5
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Interviewed regarding Resident #6's breakfast consumption and meal ticket | |
| Dietary Manager | Interviewed about Resident #6's food preferences and ice machine status | |
| State Agent (SA) | Inquired about Resident #6's breakfast | |
| Director of Nurses (DON) | Confirmed presence of black substance on ice and discussed cleaning responsibilities | |
| Maintenance Director | Confirmed responsibility for cleaning ice machines monthly and described cleaning process | |
| Infection Control Nurse and Licensed Practical Nurse (LPN) #1 | Confirmed black substance on ice was likely mold and could cause gastrointestinal upset | |
| Administrator | Confirmed ice machine cleaning policy and acknowledged failure to follow resident food preferences |
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