Inspection Reports for
Union County Health and Rehabilitation Center
1111 Bratton Road, New Albany, MS, 38652
Back to Facility Profile34 Reports
Inspection Report — Sep 10, 2026
Annual Inspection
Date: Sep 10, 2026
Visit Reason
The State Agency conducted a desk review of information related to the annual recertification survey completed from 08/03/26 through 08/06/26.
Findings
The information provided by the facility confirmed corrective measures were implemented and compliance with Medicare and Medicaid requirements was sustained. The facility is recommended to be placed back in compliance effective 09/09/26.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 6, 2026
Annual Inspection
Date: Aug 6, 2026
Visit Reason
The State Agency conducted an Annual Recertification survey at the facility from 08/03/26 through 08/06/26. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation and cited regulatory deficiencies F550, F641, F656, F677, F761, F812, and F880.
Findings
The facility was found not in compliance with multiple deficiencies including resident rights violations, inaccurate assessments, failure to implement comprehensive care plans, inadequate ADL care, unsafe medication storage, food safety violations, and infection prevention and control failures.
Deficiencies (7)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure a resident's right to be treated with respect for one of 52 residents reviewed, evidenced by a CNA yelling at a resident and prior complaints about the CNA's rude communication.
F0641 - Accuracy of Assessments. The facility failed to ensure Minimum Data Set assessments accurately reflected medications administered during the look-back period for two of 20 residents reviewed.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement Activities of Daily Living care plans for four of 52 residents reviewed, including failure to provide nail care, shaving, and scheduled showers.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide necessary ADL care including nail care, shaving, and bathing for four of 52 residents reviewed.
F0761 - Label/Store Drugs and Biologicals. The facility failed to store medications safely and securely, including leaving medication cups with creams unsecured at residents' bedsides and leaving a medication cart unlocked and unattended.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to maintain appropriate temperature control and discard time/temperature control foods, failed to consistently monitor and document food storage and holding temperatures, and left a breakfast tray with cooked sausage at bedside for over three hours without temperature control.
F0880 - Infection Prevention & Control. The facility failed to implement infection prevention and control practices for three of five resident care practices observed, including failure to empty suction canisters, improper catheter care, failure to use gowns during care requiring enhanced barrier precautions, and leaving an uncovered basin with emesis in a resident's room.
Report Facts
Deficiencies cited: 7
Inspection Report — Aug 4, 2026
Life Safety
Date: Aug 4, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Nov 4, 2025
Complaint Investigation
Date: Nov 4, 2025
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI #2627262) at the facility on 11/04/25.
Complaint Details
Complaint CI #2627262 was investigated and found to have no deficiencies related to resident neglect; the facility was in compliance.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services. There were no deficiencies cited related to resident neglect.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Sep 2, 2025
Annual Inspection
Date: Sep 2, 2025
Visit Reason
On 09/02/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 08/14/25. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 08/31/25. No deficiencies were cited in this desk review.
Inspection Report — Aug 14, 2025
Annual Inspection
Date: Aug 14, 2025
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 8/12/25 through 8/14/25. During the survey, the SA determined that the facility was not in compliance with the Medicare and Medicaid requirements for participation and cited regulatory deficiency F584.
Findings
The facility was found not in compliance due to failure to maintain a safe, clean, comfortable, and homelike environment as evidenced by dirty wheelchairs for two residents. The facility failed to ensure wheelchairs were cleaned regularly, confirmed by observations and staff interviews.
Deficiencies (1)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to ensure a clean home-like environment as evidenced by dirty wheelchairs for two residents, Resident #43 and Resident #53, with thick grayish substances and food particles on their wheelchairs.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 14, 2025
Life Safety
Date: Aug 14, 2025
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility met all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Aug 14, 2025
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to ensure a clean home-like environment as two of fifty-five residents' wheelchairs were found to be dirty with thick grayish substances and food particles. Interviews with staff confirmed responsibility for cleaning wheelchairs but noted lapses in cleaning.
Deficiencies (1)
F 0584: The facility failed to maintain a safe, clean, and homelike environment as evidenced by dirty wheelchairs for two residents, Resident #43 and Resident #53, with thick grayish substances and food particles present.
Report Facts
Residents using wheelchairs: 55
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Confirmed night shift CNAs were responsible for cleaning wheelchairs and acknowledged the wheelchairs of Residents #43 and #53 were dirty | |
| Licensed Practical Nurse (LPN) #1 | Confirmed night shift CNAs were responsible for cleaning wheelchairs and mentioned a list of wheelchairs to be cleaned | |
| Director of Nurses (DON) | Confirmed dirty wheelchairs for Residents #43 and #53 and discussed prior conversations about cleaning all wheelchairs |
Inspection Report — Sep 24, 2024
Annual Inspection
Date: Sep 24, 2024
Visit Reason
On 09/24/24 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey that was completed on 08/08/24.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that the facility be placed back in compliance effective 09/20/24.
Inspection Report — Aug 8, 2024
Annual Inspection
Date: Aug 8, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification at the facility from 8/05/24 through 8/08/24. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F550, F580, F584, and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to resident dignity, notification of changes, safe environment, and infection prevention and control.
Deficiencies (4)
F0550 - Resident Rights/Exercise of Rights. The facility failed to promote the dignity of a resident with a urinary catheter bag visible without a privacy cover, exposing the resident to loss of dignity and privacy.
F0580 - Notify of Changes (Injury/Decline/Room, etc.). The facility failed to notify the physician before holding a resident's long-acting insulin for one resident, increasing risk of adverse outcomes.
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to maintain the building in a safe manner for one resident due to a bent metal frame around a sprinkler system control panel protruding from the wall, posing a risk of injury.
F0880 - Infection Prevention & Control. The facility failed to prevent the spread of infection as evidenced by a urinary catheter bag and drainage tubing laying on the floor for one resident and failure to perform hand hygiene after handling a urinary catheter bag during wound care for another resident.
Report Facts
Deficiencies cited: 4
Inspection Report — Aug 8, 2024
Routine
Date: Aug 8, 2024
Visit Reason
Routine inspection to assess compliance with regulatory standards related to resident dignity, medication administration, building safety, and infection control at Union CO Health and Rehab Center, Inc.
Findings
The facility was found deficient in promoting resident dignity by failing to provide privacy bags for urinary catheters, failing to notify physicians before holding long-acting insulin for a resident, maintaining a hazardous bent metal sprinkler panel frame in a resident's room, and failing to prevent infection risks related to catheter bag placement and hand hygiene during wound care.
Deficiencies (4)
F 0550: The facility failed to promote the dignity of a resident by not providing a privacy bag for a urinary catheter, leaving the catheter bag visible from the doorway.
F 0580: The facility failed to notify the physician before holding a resident's long-acting insulin for one of 14 residents reviewed.
F 0584: The facility failed to maintain the building safely by allowing a bent metal frame around a sprinkler panel in a resident's room to protrude, posing a risk of injury.
F 0880: The facility failed to prevent infection spread by allowing a urinary catheter bag and drainage tubing to lay on the floor and failing to perform hand hygiene after handling the catheter bag during wound care.
Report Facts
Residents with catheters observed: 5
Residents reviewed for insulin administration: 14
Resident rooms observed: 47
Care area observations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) #2 | Confirmed no privacy bag was used for Resident #26's catheter | |
| Licensed Practical Nurse (LPN) #2 | Confirmed all residents with catheters should have privacy bags and catheter bags should not touch the floor | |
| Infection Preventionist | Confirmed privacy bag use and catheter bag infection risk | |
| Director of Nursing (DON) | Confirmed LPN #4 should have notified physician before holding insulin and acknowledged sprinkler panel hazard and hand hygiene failures | |
| Licensed Practical Nurse (LPN) #4 | Held insulin without notifying physician | |
| Licensed Practical Nurse (LPN) #3 | Stated physician notification is required before holding insulin | |
| Nurse Practitioner | Confirmed not notified about insulin being held | |
| Maintenance Staff | Acknowledged bent sprinkler panel frame was dangerous | |
| Certified Nursing Assistant (CNA) #1 | Noticed bent sprinkler panel frame but did not notify charge nurse | |
| Housekeeper | Unaware of bent sprinkler panel frame and prevention measures | |
| Licensed Practical Nurse (LPN) #1 | Failed to perform hand hygiene after handling catheter bag during wound care |
Inspection Report — Aug 6, 2024
Life Safety
Date: Aug 6, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Feb 12, 2024
Complaint Investigation
Date: Feb 12, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS#23795) at the facility on 02/12/24 related to neglect involving a resident being over medicated and dehydrated.
Complaint Details
CI MS#23795 - Allegation of neglect related to a resident being over medicated and dehydrated; the complaint was investigated and 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
Complaints investigated: 1
Inspection Report — Nov 21, 2023
Complaint Investigation
Date: Nov 21, 2023
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #23323 and CI MS #23324) at the facility from 11/20/23 through 11/21/23. The investigations focused on neglect related to falls, leaving residents unattended, not providing grooming needs, not giving medications as ordered, and leaving residents wet and soiled for long periods of time.
Complaint Details
Complaint numbers CI MS #23323 and CI MS #23324 involved allegations of neglect related to falls, unattended residents, unmet grooming needs, medication errors, and residents left wet and soiled. The complaints were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Sep 12, 2023
Complaint Investigation
Date: Sep 12, 2023
Visit Reason
On 09/12/23 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 08/09/23. The review confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
Complaint CI MS#26995 was investigated through a desk review and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. No deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — Sep 5, 2023
Complaint Investigation
Date: Sep 5, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS #22577) at the facility on 09/05/23.
Complaint Details
Complaint number CI MS #22577 was investigated and found to be unsubstantiated with no deficiencies cited related to medication administration.
Findings
The facility was found in compliance with Medicare and Medicaid participation requirements and no deficiencies related to medication administration were cited. However, the facility remains out of compliance due to deficiencies cited on the 8/9/2023 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 9, 2023
Complaint Investigation
Date: Aug 9, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS #22155, CI MS #22051, and CI MS #21990) at the facility from 08/08/23 through 08/09/23. The facility was found not in compliance with Medicare and Medicaid requirements due to failure to maintain accurate medical records for CI MS #21990. No deficiencies were cited for CI MS #22155 and CI MS #22051 related to staffing and resident safety.
Complaint Details
Complaint investigation CI MS #21990 was substantiated with a deficiency cited for failure to maintain accurate medical records. Complaints CI MS #22155 and CI MS #22051 were not substantiated and no deficiencies were cited related to staffing and resident safety.
Findings
The facility was cited for failure to maintain accurately documented medical records on pressure ulcers for one of five residents reviewed. The documentation did not accurately reflect the wound stage and acquisition status, leading to inaccurate medical records.
Deficiencies (1)
F0842 - Resident records were not accurately documented regarding pressure ulcers for one resident, including incorrect wound staging and failure to document wounds as facility-acquired.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 9, 2023
Date: Aug 9, 2023
Visit Reason
The inspection was conducted to assess compliance with medical record documentation standards, specifically regarding accurate documentation of pressure ulcers for residents.
Findings
The facility failed to maintain accurate medical records on pressure ulcers for one of five residents reviewed. Documentation errors included misclassification of pressure ulcers and inaccurate recording of wound status as hospital-acquired when they were present on admission.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain accurate medical records on pressure ulcers for Resident #1. The wounds were not properly staged prior to hospital transfer and were inaccurately documented as hospital-acquired.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1, charge nurse | Interviewed regarding wound care and documentation for Resident #1 | |
| Registered Nurse (RN) #2, Wound Care Supervisor | Interviewed regarding wound staging and documentation for Resident #1 | |
| Director of Nursing (DON) | Interviewed regarding wound treatment and documentation accuracy for Resident #1 | |
| Administrator (ADM) | Interviewed regarding facility's acknowledgment of documentation issues |
Inspection Report — May 30, 2023
Annual Inspection
Date: May 30, 2023
Visit Reason
On 05/30/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 05/04/23.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that your facility be placed back in compliance effective 05/26/23.
Inspection Report — May 30, 2023
Date: May 30, 2023
Visit Reason
On 05/30/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 05/04/23. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 05/26/23. No deficiencies were cited in this desk review.
Inspection Report — May 4, 2023
Annual Inspection
Date: May 4, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 05/01/23 through 05/04/23. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F583, F656, and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to deficiencies in resident privacy during incontinent care, failure to implement comprehensive care plans related to catheter care, and inadequate infection prevention and control practices.
Deficiencies (3)
F0583 - Personal privacy/confidentiality of records. The facility failed to provide privacy to a resident during incontinent care by not closing window blinds, exposing the resident to view from outside.
F0656 - Develop/implement comprehensive care plan. The facility failed to implement the care plan related to proper handling of a catheter bag by allowing staff to hold the catheter bag above the level of the resident's bladder during transfer.
F0880 - Infection prevention & control. The facility failed to prevent the spread of infection by not performing hand hygiene during incontinent care for a resident.
Report Facts
Deficiencies cited: 3
Inspection Report — May 4, 2023
Routine
Date: May 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, care plan implementation, and infection prevention and control practices at the nursing home.
Findings
The facility failed to provide privacy during incontinent care by not closing window blinds, did not follow the care plan for proper catheter bag handling, and failed to perform hand hygiene during catheter care, posing potential risks to residents.
Deficiencies (3)
F 0583: The facility failed to provide privacy to a resident during incontinent care by not closing the window blinds in the resident's room.
F 0656: The facility failed to implement the care plan related to proper handling of a catheter bag by holding it above bladder level during resident transfer.
F 0880: The facility failed to prevent infection spread by not performing hand hygiene during incontinent care for a resident.
Report Facts
Residents observed for incontinent care: 3
Care plans reviewed: 13
Brief Interview for Mental Status (BIMS) score: 7
Brief Interview for Mental Status (BIMS) score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Failed to close window blinds during incontinent care | |
| Certified Nursing Assistant (CNA) #2 | Held catheter bag above bladder level during resident transfer | |
| Certified Nursing Assistant (CNA) #3 | Held catheter bag above bladder level and failed to perform hand hygiene during catheter care | |
| Director of Nursing (DON) | Confirmed privacy and care plan deficiencies and infection control issues |
Inspection Report — May 2, 2023
Life Safety
Date: May 2, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Apr 13, 2022
Complaint Investigation
Date: Apr 13, 2022
Visit Reason
The State Agency conducted complaint surveys for CI MS#18110, CI MS#18189, and CI MS#18346 along with a focused Infection Control Survey from 04/12/2021 through 04/13/2022.
Complaint Details
Complaints CI MS#18110, CI MS#18189, and CI MS#18346 were investigated and not substantiated; no deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards for the Institutions for the Aged or Infirmed. No deficiencies were cited and the complaints were not substantiated.
Report Facts
Complaints investigated: 3
Inspection Report — Apr 13, 2022
Routine
Date: Apr 13, 2022
Visit Reason
Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 04/12/2022-04/13/2022.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Aug 4, 2021
Complaint Investigation
Date: Aug 4, 2021
Visit Reason
The State Agency conducted a complaint survey for complaints #17945, CI #17946, CI #17947 and CI #17902 from 8/2/21 through 8/4/21.
Complaint Details
Complaints #17945, CI #17946, CI #17947 and CI #17902 were investigated and found not substantiated 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. The complaints were not substantiated and no deficiencies were cited.
Report Facts
Complaints investigated: 4
Inspection Report — Apr 13, 2021
Annual Inspection
Date: Apr 13, 2021
Visit Reason
The State Agency conducted an annual survey at the facility from 03/15/21 through 03/18/21, along with complaint investigations (CI) MS #17626, #17627, #17607, #17562, #17533, #17534, #17535, #17517, #17513, #17514, #17658, and #17661 all related to Quality of Care.
Complaint Details
Complaint investigations MS #17626, #17627, #17607, #17562, #17533, #17534, #17535, #17517, #17513, #17514, #17658, and #17661 were related to Quality of Care. Only CI MS #17513 was substantiated for failure to report an allegation of abuse and/or neglect; all other complaints were unsubstantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations and substantiated complaint investigation MS #17513 related to failure to report an allegation of abuse and/or neglect. Additional deficiencies were cited for failure to notify of a transfer and infection control related to dietary staff not wearing masks in the kitchen.
Deficiencies (3)
F0609 - Failure to report an allegation of abuse and/or neglect as substantiated in complaint investigation MS #17513.
F0623 - Failure to notify of a transfer.
F0880 - Infection control deficiency related to dietary staff failing to wear masks while in the kitchen.
Report Facts
Deficiencies cited: 3
Inspection Report — Mar 18, 2021
Annual Inspection
Date: Mar 18, 2021
Visit Reason
The State Agency conducted an annual survey at the facility from 03/15/21 through 03/18/21, along with complaint investigations related to Quality of Care.
Complaint Details
Complaint investigations CI MS #17626, CI MS #17627, CI MS #17607, CI MS #17562, CI MS #17533, CI MS #17534, CI MS #17535, CI MS #17517, CI MS #17513, CI MS #17514, CI MS #17658, and CI MS #17661 were related to Quality of Care. The SA substantiated CI MS #17513 at F609 related to failure to report an allegation of abuse and/or neglect. All other complaints were unsubstantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations, citing deficiencies in failure to notify family in writing of hospital transfers and failure to ensure dietary staff wore masks in the kitchen, posing infection control risks.
Deficiencies (3)
F0623 - The facility failed to notify the family in writing of a hospital transfer for one resident, despite policy requiring written and verbal notification.
F0880 - The facility failed to prevent possible spread of infection by dietary employees not wearing face masks in the kitchen during three observations.
F0609 - Failure to report an allegation of abuse and/or neglect, substantiated in complaint investigation CI MS #17513.
Report Facts
Deficiencies cited: 3
Inspection Report — Mar 15, 2021
Life Safety
Date: Mar 15, 2021
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Jul 27, 2020
Routine
Date: Jul 27, 2020
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period in July 2020.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network as required by regulation during a seven-day period.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 20, 2020
Routine
Date: Jul 20, 2020
Visit Reason
The State Agency conducted a focused infection control survey related to COVID-19 reporting requirements.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Deficiencies (1)
F0884 - The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/24/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/24/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 8, 2019
Annual Inspection
Date: Aug 8, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 8/5/19 to 8/8/19.
Findings
The facility was found in compliance with Medicare and Medicaid requirements with no regulatory deficiencies cited.
Report Facts
Deficiencies cited: 0
4 CMS Surveys
CMS Survey — Aug 9, 2023
Aug 9, 2023
CMS Survey — May 4, 2023
May 4, 2023
CMS Survey — Aug 8, 2024
Aug 8, 2024
CMS Survey — Aug 14, 2025
Aug 14, 2025
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