Inspection Reports for Vineyard Court Nursing Center

The State Agency conducted four complaint investigations at the facility from 12/22/2025 through 12/23/2025 related to accidents, abuse, neglect, misappropriation of property, resident rights, nursing service, and quality of care.

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

Four complaint investigations (CI MS #2682458, CI MS #2685521, CI MS #2687158, and CI MS #2695403) were conducted covering accidents, abuse, neglect, misappropriation of property, resident rights, nursing service, and quality of care. No deficiencies were cited.

The State Agency conducted four complaint investigations at the facility from 12/22/2025 through 12/23/2025 related to accidents, abuse, neglect, misappropriation of property, resident rights, nursing service, and quality of care.

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

Four complaint investigations (CI MS #2682458, CI MS #2685521, CI MS #2687158, and CI MS #2695403) were conducted covering accidents, abuse, neglect, misappropriation of property, resident rights, nursing service, and quality of care; no deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI MS #2654902) at the facility on 11/20/2025 for resident safety.

During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements with no deficiencies cited. However, the facility remains out of compliance due to deficiencies cited in prior surveys on August 27, 2025 and September 23, 2025.

Complaint Investigation (CI MS #2654902) was investigated for resident safety and found no deficiencies during this visit.

The State Agency conducted a Complaint Investigation (CI MS #2654902) at the facility on 11/20/2025 regarding resident rights.

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, but the facility remains out of compliance due to deficiencies cited in prior surveys on August 27, 2025 and September 23, 2025.

Complaint Investigation (CI MS #2654902) regarding resident rights was conducted and found no deficiencies; facility remains out of compliance due to prior surveys.

The State Agency conducted a follow-up revisit at the facility on 11/20/25 related to a complaint survey conducted on 09/23/25.

The State Agency determined the facility was in compliance with Medicare and Medicaid participation requirements and recommends the facility be placed back in compliance effective 11/14/25.

The visit was related to a complaint survey conducted on 09/23/25; the follow-up determined compliance.

The State Agency conducted a follow-up revisit at the facility on 11/20/25 related to a complaint survey conducted on 09/23/25.

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 into compliance effective 11/14/25.

The follow-up revisit was related to a complaint survey conducted on 09/23/25. The facility was found to be in compliance.

The State Agency conducted a follow-up revisit at the facility on 11/20/25 related to a complaint survey conducted on 08/27/25 to verify corrective measures.

The facility corrected the violations found on 08/27/25 as of 10/03/25, but remained out of compliance until 11/14/25, the compliance date of the 09/23/25 survey.

Visit was related to a complaint survey conducted on 08/27/25; corrective measures were verified during this follow-up.

The State Agency conducted a follow-up revisit at the facility on 11/20/2025 related to a complaint survey conducted on 08/27/2025 to verify correction of previous deficiencies.

The facility corrected the violations found on 08/27/2025 as of 10/03/2025, but remained out of compliance with state licensure requirements until 11/14/2025, the compliance date of the 09/23/2025 survey.

The visit was related to a complaint survey conducted on 08/27/2025. The corrective measures were determined to have corrected the violations by 10/03/2025.

The State Agency conducted four complaint investigations at the facility from 9/22/25 through 9/23/25 related to quality of care, resident rights, verbal abuse, abuse, misappropriation, positioning of residents, and neglect.

The facility failed to ensure residents were treated with dignity and respect, evidenced by inappropriate language used by staff and lack of privacy during care for two residents. Specific incidents included a CNA checking a resident's brief in a hallway and another CNA using profanity towards a resident.

The complaint investigations included issues of quality of care related to positioning, resident rights, hydration, verbal abuse, abuse, misappropriation, and neglect. The facility was cited for failure to protect resident rights in all four complaint investigations.

The State Agency conducted four complaint investigations at the facility from 9/22/25 through 9/23/25 related to residents' rights and compliance with state licensure regulations.

The facility failed to ensure residents were treated with dignity and respect, evidenced by inappropriate language used by staff and lack of privacy during care for two residents. Specific incidents involved a CNA checking a resident's brief in a hallway and another CNA using profanity towards a resident.

Four complaint investigations were conducted (CI MS #2614098, CI MS #2614922, CI MS #2614963, and CI MS #2625345) focusing on residents' rights. The complaints were substantiated by observations, interviews, and record reviews showing violations of dignity, respect, and privacy.

The State Agency conducted two complaint investigations at the facility from 8/26/25 through 8/27/25 related to discharge rights, quality of care, resident neglect, and pain medication.

The facility failed to adequately supervise residents during smoking breaks, allowing residents to smoke marijuana, and failed to provide an ordered pain medication for a resident who had pain.

The complaint investigations were MS #491260 related to discharge rights and quality of care, and MS #2585966 related to resident neglect and quality of care related to pain medication.

The State Agency conducted two complaint investigations at the facility from 8/26/25 through 8/27/25 related to resident neglect and quality of care regarding pain medication availability and accidents/hazards involving resident smoking behavior.

The facility failed to adequately supervise residents during smoking breaks, allowing two residents to smoke marijuana. Additionally, the facility failed to provide an ordered pain medication to a resident who had pain due to staff not following medication procurement procedures.

Two complaint investigations were conducted: CI MS #2585966 related to resident neglect and quality of care concerning unavailable pain medication, and CI MS #491260 related to accidents/hazards involving resident smoking marijuana.

The State Agency conducted a desk review of information related to the annual survey completed on 2025-02-20 to verify compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was confirmed to be in compliance as of 2025-03-17 based on the desk review; however, the facility remains out of compliance due to deficiencies cited on the 2025-02-20 Life Safety Code survey.

The State Agency conducted a desk review of information related to the annual survey completed on 2025-02-20 to verify corrective measures taken by the facility.

The facility had implemented measures to correct deficient practices and sustain compliance as of 2025-03-17; however, it remains out of compliance due to deficiencies cited in the 2025-02-20 Life Safety Code survey.

The State Agency conducted a Complaint Investigation (CI) MS #28096 at the facility on 3/11/25 to investigate allegations of abuse and neglect.

The facility was found to be in compliance with Medicare and Medicaid requirements, with no deficiencies cited related to abuse and neglect. However, the facility remains out of compliance due to deficiencies cited on 2/20/25.

The complaint investigation involved allegations of abuse and neglect, which were not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation at the facility on 3/11/25 to determine compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.

The facility was found in compliance with resident rights with no deficiencies cited during this investigation; however, the facility remains out of compliance due to deficiencies cited on 2/20/25.

Complaint Investigation MS #28096 was conducted; no deficiencies were cited related to resident rights during this investigation.

The State Agency conducted an annual recertification survey at the facility from 02/18/2025 through 02/20/2025 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with state standards, citing deficiencies related to failure to provide adequate range of motion services for a resident and failure to implement proper infection control practices for two residents, including improper use and storage of anti-contracture devices, PEG tube equipment, and nebulizer masks.

The State Agency conducted an annual recertification survey at Vineyard Court Nursing Center from 02/18/2025 through 02/20/2025 to determine compliance with Medicare and Medicaid requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to failure to implement comprehensive care plans for anti-contracture devices, failure to provide services to maintain or improve range of motion, and failure to implement infection prevention and control practices for residents with PEG tubes and nebulizer treatments.

The inspection was conducted as part of the annual survey to assess compliance with emergency preparedness and Life Safety Code requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited. The State Agency conducted a desk review on 03/24/25 and recommended the facility be placed back in compliance effective that date.

The inspection was conducted to assess compliance with the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), specifically focusing on smoke barrier construction and fire safety measures.

The facility failed to provide 20-minute fire resistance rating smoke barrier doors in accordance with NFPA 101 standards. Specifically, the East Hall smoke barrier doors did not properly close upon activation of the fire alarm and sprinkler systems, affecting two of five smoke compartments and 33 of 54 residents.

The State Agency conducted two onsite complaint investigations for quality of care concerns.

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

Two onsite complaint investigations (CI MS #26513 and CI MS #26547) were conducted; no deficiencies were cited.

The State Agency conducted two onsite complaint investigations for allegations of quality of care concerns.

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

Two complaint investigations (CI MS #26513 and CI MS #26547) alleging quality of care concerns were conducted and found to be unsubstantiated with no deficiencies cited.

The State Agency conducted a desk review related to a complaint survey completed on 2024-06-04 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-07-05.

The visit was related to a complaint survey completed on 2024-06-04. The facility's corrective measures were reviewed and found satisfactory.

The State Agency conducted a desk review related to a complaint survey completed on 2024-06-04 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2024-07-05.

The visit was complaint-related, reviewing information from a complaint survey completed on 2024-06-04. The facility was found in compliance and the complaint was effectively resolved.

The State Agency conducted a Complaint Investigation at Vineyard Court Nursing Center on 06/03/24 through 06/04/24 related to allegations including abuse and accidents.

The facility was found not in compliance with Minimum Standards due to failure to immediately notify administrative staff and local police when a cognitively intact resident left the facility on foot. The resident was found safe but the incident revealed deficiencies in staff response and reporting procedures.

The complaint investigation included two complaint numbers (MS# 25238 and MS# 25334). The investigation of MS# 25334 related to an allegation of abuse found no deficiencies. The investigation of MS# 25238 found deficiencies related to accident reporting and resident safety.

The State Agency conducted two complaint investigations at the facility from 06/03/2024 through 06/04/2024. One investigation (CI MS #25238) was for accidents and hazards, and the other (CI MS #25334) was for alleged abuse.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to immediately notify administrative staff and local police when a cognitively intact resident left the facility on foot after returning from a pass. The resident was found safe after being missing for several hours. No deficiencies were cited related to the abuse allegation.

The complaint investigation CI MS #25238 was substantiated with a cited deficiency (F689) related to accidents and hazards. The complaint investigation CI MS #25334 for alleged abuse was not substantiated and no deficiencies were cited.

The State Agency conducted two complaint investigations at the facility from June 3 to June 4, 2024, related to accidents and hazards (CI MS #25238) and alleged abuse (CI MS #25334). The investigation for accidents and hazards resulted in a citation, while no deficiencies were cited for alleged abuse.

The facility failed to immediately notify administrative staff and local police when a cognitively intact resident left the facility on foot after returning from a pass, resulting in a safety risk. The resident was found by police about a mile from the facility and was hospitalized. The facility implemented corrective actions including one-on-one observation, staff education, policy revisions, audits, and quality assurance meetings to prevent future elopements.

The complaint investigation CI MS #25238 was substantiated with a citation for accidents and hazards (F689). The complaint investigation CI MS #25334 for alleged abuse was not substantiated and no deficiencies were cited.

The State Agency conducted a complaint investigation (CI MS #24803) at the facility on 5/15/24.

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

Complaint investigation CI MS #24803 was conducted and found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a complaint investigation (CI MS #24803) at the facility on 5/15/24.

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

Complaint investigation CI MS #24803 was conducted and the facility was found compliant with no deficiencies cited.

The State Agency conducted a complaint investigation (CI MS #24803) at the facility on 5/15/24.

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

Complaint investigation CI MS #24803 was conducted and the facility was found compliant with no deficiencies cited.

The State Agency conducted a complaint investigation at the facility on 5/15/24.

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

Complaint investigation CI MS #24803 was conducted and found no deficiencies.

The State Agency conducted a Complaint Investigation (CI MS#23616 and CI MS#24271) at the facility from 02/14/24 to 02/27/24 to assess compliance with state licensure requirements and investigate medication administration concerns.

The facility was found in compliance with most standards except for a past non-compliance related to medication administration where a resident did not receive prescribed antiarrhythmic medication due to pharmacy backorder and staff failure to notify or obtain the medication, resulting in the resident being sent to the hospital emergency department. The responsible Licensed Practical Nurse was terminated, and corrective actions including in-services and quality assurance meetings were implemented.

Complaint Investigation MS#23616 and MS#24271. The medication administration deficiency was related to MS#24271 and was cited as past non-compliance. The facility corrected the deficiency prior to the State Agency entrance on 02/26/24. No deficiencies were related to MS#23616.

The State Agency conducted a complaint investigation triggered by complaints related to medication storage and medication administration at the facility.

The facility failed to ensure proper medication administration and storage, resulting in a resident missing two doses of an antiarrhythmic medication which led to hospitalization. Additionally, a medication bottle was left unsecured allowing a resident to access and ingest pills. The facility corrected these deficiencies prior to the survey.

The complaint investigation involved medication storage and administration issues. The facility was found non-compliant for medication errors and storage, with a resident missing doses of heart medication leading to hospitalization and another resident accessing unsecured medication. The facility conducted investigations, terminated responsible staff, provided in-services, and implemented corrective actions prior to the survey.

The State Agency conducted a revisit at the facility from 11/27/23 through 11/28/23 to verify compliance with previously cited deficiencies.

The facility was placed back into compliance for deficiencies related to administration, residents' rights, range of motion, nutrition, and medication administration effective 11/17/2023.

The State Agency conducted a revisit at the facility from 11/27/23 through 11/28/23 to verify correction of previously cited deficiencies related to resident neglect, assessments, care plans, pain management, nursing staff competency, pharmacy services, therapeutic diet, administration, and Medical Director responsibilities.

The facility was placed back into compliance for multiple previously cited deficiencies including resident neglect, assessment accuracy, care plan implementation, pain management, nursing staff competency, pharmacy services, therapeutic diet, administration, and Medical Director responsibilities effective 11/17/2023.

The State Agency conducted an annual recertification survey and complaint investigation for Resident #25's pain management concerns from 10/10/23 to 10/20/23, including an extended survey visit.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including failure to ensure timely availability of pain medications for Resident #25, leading to severe pain, emergency room visits, and suicidal ideation. The facility also failed to properly implement care plans, provide therapeutic diets, and ensure competent nursing staff. Immediate Jeopardy was identified and removed after corrective actions.

Complaint investigation MS #23049 was included in the annual recertification survey due to Resident #25's pain management concerns, including severe pain, emergency room visits, and suicidal ideation related to lack of pain medication.

The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment related to a controlled substance medication discrepancy involving Resident #14.

The facility failed to complete a thorough investigation of a controlled substance medication discrepancy involving approximately 13 milliliters of liquid Dilaudid missing for Resident #14. The investigation lacked resident interviews to confirm medication receipt and pain control, and the Administrator acknowledged inexperience with such investigations.

The complaint involved a medication discrepancy discovered on 10/9/2023, reported to the State Agency, local Police Department, Responsible Party, and Attorney General. The investigation was incomplete, lacking resident interviews and thorough documentation.

The State Agency conducted an annual recertification survey and complaint investigation which began on 2023-10-10 and concluded on 2023-10-20. The visit included an extended survey and complaint investigation related to pain management and medication availability.

The facility was found not in compliance with Minimum Standards of Operation and cited for deficiencies including Immediate Jeopardy related to failure to provide timely pain medication to Resident #25, resulting in severe pain and mental anguish. The facility also failed to apply an anti-contracture device for Resident #32 and failed to serve a therapeutic diet as ordered for Resident #26. The Immediate Jeopardy was removed after corrective actions were implemented.

Complaint investigation MS #23049 was conducted concurrently with the annual recertification survey. The complaint involved allegations of inadequate pain management for Resident #25, including failure to provide prescribed pain medication timely, resulting in severe pain and mental anguish. The complaint was substantiated with Immediate Jeopardy identified and later removed after corrective actions.

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

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this inspection.

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

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

The State Agency conducted a complaint investigation at the facility on 09/05/23 for MS00022301.

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

Complaint investigation for MS00022301; no deficiencies were cited indicating compliance.

The State Agency conducted a complaint investigation at the facility for CI MS #22301.

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

Complaint investigation for CI MS #22301; no deficiencies were cited.

The State Agency conducted a complaint investigation for MS #21699 at the facility on 7/6/23.

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

Complaint investigation for MS #21699; no deficiencies were cited indicating the complaint was not substantiated.

The State Agency conducted a complaint investigation for MS #21699 at the facility on 7/6/23.

The facility was found to be in compliance with Medicare and Medicaid Services requirements and no deficiencies were cited.

Complaint investigation for MS #21699 was conducted and found no deficiencies; facility was compliant.

The State Agency conducted an on-site complaint investigation for MS00019403 from 10/04/22 through 10/05/22.

The State Agency found that the facility was in compliance with the regulations for The Aged and Infirm.

Complaint investigation for MS00019403; facility found in compliance.

The State Agency conducted an on-site complaint investigation for MS00019403 from 10/04/22 through 10/05/22.

During the investigation, the State Agency found that the facility was in compliance with the requirements for Medicare and Medicaid Services.

Complaint investigation for MS00019403 found the facility in compliance.

The State Agency conducted a recertification survey at the facility from 5/16/22 through 5/19/22 to determine compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm requirements.

The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm requirements at the time of the survey.

The State Agency conducted an annual recertification survey at the facility from 5/16/2022 through 5/19/2022 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies in resident assessment accuracy after significant change, coordination of PASARR, and infection control practices, all at a D level severity.

The State Agency conducted a desk review of information related to the annual survey conducted on 05/19/22 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

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

The State Agency conducted a desk review related to the annual survey conducted on 05/19/22 to assess the facility's compliance with Medicare and Medicaid requirements.

The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance. The State Agency recommended the facility be placed back in compliance effective 06/10/22.

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).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No LSC deficiencies were cited during this survey.

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).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No LSC deficiencies were cited during this survey.

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

The facility met all applicable Federal, State, and local emergency preparedness requirements as of the survey date.

The State Agency conducted a revisit for complaint investigation MS #17831 on 8/12/21 at the facility.

The State Agency determined that the facility was in compliance with Mississippi Regulations for Minimum Standards for Aged or Infirm as of 8/1/21 related to M500.

Revisit for complaint investigation MS #17831; facility found in compliance.

The State Agency conducted a revisit for complaint investigation MS #17831 on 8/12/21 at the facility to determine compliance with Medicare and Medicaid regulations related to F603 and F610.

The State Agency determined that the facility was in compliance with Medicare and Medicaid regulations for participation as of 8/1/21 related to F603 and F610.

Revisit for complaint investigation MS #17831; facility found in compliance as of 8/1/21.

The surveyor conducted a complaint investigation related to allegations of abuse and neglect, as well as issues concerning the physical environment and facility equipment.

The complaint investigation was unable to substantiate the allegations. The facility remains out of compliance from the previous survey.

Complaint investigation for CI# 17342 and CI#17022 related to abuse and neglect, and CI# 17474 and CI# 16967 related to physical environment and facility equipment; allegations were not substantiated.

The State Agency conducted a complaint investigation from 6/17/21 to 6/21/21 regarding a complaint alleging involuntary seclusion of Resident #1 by staff placing a linen cart and lift in front of the resident's door to prevent exit.

The facility failed to protect Resident #1 from involuntary seclusion and allowed the responsible nurse (RN #5) to continue working after the incident, placing residents at risk of serious harm. Immediate Jeopardy was identified and later removed after corrective actions including staff termination, in-services, and monitoring were implemented.

The complaint investigation substantiated the allegation of involuntary seclusion of Resident #1. Immediate Jeopardy and Substandard Quality of Care were identified beginning 6/7/21 when RN #5 instructed CNA #4 to block Resident #1's door with a linen cart and lift. RN #5 was not suspended immediately and continued working until terminated on 6/18/21.

The State Agency conducted a complaint investigation from 6/17/21 to 6/21/21 regarding allegations of involuntary seclusion and related abuse at Vineyard Court Nursing Center.

The facility was found to have placed Resident #1 in involuntary seclusion by blocking his room door with a linen cart and lift, causing mental anguish and risk of physical harm. The facility failed to suspend the responsible nurse immediately, allowing her to continue working. The situation was deemed Immediate Jeopardy and Substandard Quality of Care, which was removed after corrective actions including staff in-services, monitoring, and termination of involved employees.

The complaint investigation substantiated the allegation of involuntary seclusion of Resident #1. The facility was cited for Immediate Jeopardy and Substandard Quality of Care. The responsible nurse was allowed to work multiple shifts after the incident before termination. The facility failed to suspend the nurse pending investigation and delayed reporting to the Board of Nursing.

A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 12/28/20 to assess infection control compliance.

No new observations related to infection control were noted during this survey; however, the facility remains out of compliance based on deficiencies cited during the 12/23/20 COVID-19 Focused Infection Control survey.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/28/20 to assess compliance with emergency preparedness regulations related to COVID-19.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness for COVID-19.

A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and CMS/CDC recommended practices related to COVID-19.

The facility failed to consistently use signage to identify COVID-19 positive and negative resident rooms, with one of eight rooms on one hallway lacking proper signage. Staff were in-serviced on a new system of red and green tags to indicate COVID-19 status, and monitoring was implemented to ensure compliance.

A COVID-19 Emergency Preparedness Survey was conducted by the State Agency on 12/23/20 to assess compliance with federal regulations related to emergency preparedness.

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

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

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

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

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

The State Agency conducted an onsite complaint investigation on 1/17/2020 for a facility self-reported complaint, CI MS #16404 that allegedly took place on 11/07/2019.

The complaint was partly substantiated with no facility deficiencies cited. The facility was determined to be in substantial compliance with Medicaid and Medicare participation requirements.

Complaint CI MS #16404 was partly substantiated with no deficiencies cited.

The State Agency conducted an annual recertification survey and complaint survey at the facility from 06/24/2019 to 06/27/2019 to assess compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance due to inaccurate completion of the Minimum Data Set (MDS) assessments for two residents, specifically related to anticoagulant medication coding and wandering status. No deficiencies were substantiated related to the complaints, and no adverse outcomes were identified for the affected residents.

The complaint investigations CI MS #15832 and CI MS #15858 were not substantiated related to quality of care, and no deficiencies were cited related to the complaints.

The State Agency conducted an annual recertification survey along with complaint investigations from 6/24/19 to 6/27/19 to assess compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with Medicare and Medicaid requirements. The State Agency did not substantiate the complaints related to quality of care but cited deficient practice at tag F641 during the survey.

Complaints MS#15832 and MS#15858 were investigated but not substantiated related to quality of care, with no citations related to the complaints.