Inspection Reports for
Wisteria Gardens
5420 Highway 80 East, Pearl, MS, 39208
Back to Facility Profile32 Reports
Inspection Report — Apr 15, 2026
Life Safety
Date: Apr 15, 2026
Visit Reason
On 04/15/26 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 03/09/26. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code.
Findings
The survey conducted on 03/09/26 revealed the facility met all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Apr 14, 2026
Date: Apr 14, 2026
Visit Reason
On 04/14/26 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 03/11/26. 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 your facility be placed back in compliance effective 04/13/26.
Inspection Report — Apr 14, 2026
Annual Inspection
Date: Apr 14, 2026
Visit Reason
On 04/14/26 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 03/11/26.
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 your facility be placed back in compliance effective 04/13/26.
Inspection Report — Mar 11, 2026
Annual Inspection
Date: Mar 11, 2026
Visit Reason
The State Agency (SA) conducted an Annual Recertification survey at the facility from 03/09/2026 through 03/11/2026. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F689 and F880.
Findings
The facility was found not in compliance due to failure to ensure a safe smoking program and failure to follow infection prevention and hand hygiene practices during catheter care.
Deficiencies (2)
F0689 - The facility failed to ensure a safe smoking program and failed to assess a resident for safe smoking practices for one of three residents reviewed for accident hazards. Resident #17 was observed with cigarettes in his shirt pocket and no smoking assessment was completed. The designated smoking area lacked safety equipment such as aprons, fire extinguisher, and barriers.
F0880 - The facility failed to ensure staff followed infection prevention and hand hygiene practices during catheter care for one of three residents observed. CNA #1 wiped the resident's perineal area multiple times with contaminated gloves without changing gloves or performing hand hygiene, risking infection transmission. The Director of Nursing confirmed this was improper practice.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 11, 2026
Annual Inspection
Date: Mar 11, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 03/09/2026 to 03/11/2026. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for the Aged or Infirm, state licensure requirements and cited M640 and M1570.
Findings
The facility was found not in compliance with state licensure requirements due to failure to ensure a safe smoking program and failure to follow infection control practices during catheter care.
Deficiencies (2)
M0640 - The facility failed to ensure a safe smoking program and failed to assess a resident for safe smoking practices for one of three residents reviewed for accident hazards. Observations and interviews revealed cigarettes kept in resident's shirt pocket, lack of smoking assessments, no smoking aprons or fire extinguisher in the designated smoking area, and no staff training on smoking safety.
M1570 - The facility failed to ensure staff followed infection prevention and hand hygiene practices during catheter care for one of three residents observed. A Certified Nurse Aide was observed wiping a resident's bleeding perineal area multiple times with the same contaminated gloves without changing gloves or performing hand hygiene, increasing risk of infection.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 9, 2026
Life Safety
Date: Mar 9, 2026
Visit Reason
The Life Safety Code survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility failed to properly document records of testing the generator annually as required by NFPA 110 and NFPA 99, affecting the entire facility with 44 residents on the day of the survey.
Deficiencies (1)
K0918 - The facility failed to properly document records of testing the generator annually as required by NFPA 110 and NFPA 99, affecting all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 25, 2025
Annual Inspection
Date: Mar 25, 2025
Visit Reason
On 03/25/25 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 02/20/25.
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 your facility be placed back in compliance effective 03/21/25.
Inspection Report — Feb 20, 2025
Annual Inspection
Date: Feb 20, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 02/18/2025 through 02/20/2025. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F641, F759, F761, F812, F865 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies cited in assessment accuracy, medication errors, drug storage, food safety, quality assurance, and infection control.
Deficiencies (6)
F0641 - Accuracy of Assessments. The facility failed to correctly code a Minimum Data Set (MDS) discharge assessment for one of fourteen sampled residents, Resident #48, due to misinterpretation of progress notes.
F0759 - Free of Medication Error Rates 5 Percent or More. The facility failed to ensure the medication error rate was less than 5%, with three errors observed out of 29 medication administration opportunities affecting two residents.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure medications were safely and securely stored for one resident, Resident #43, with medications improperly left at the bedside.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store food and maintain sanitary practices, with expired, freezer burned, improperly stored, unlabeled, and undated foods observed in the kitchen.
F0865 - QAPI Program/Plan, Disclosure/Good Faith Attempt. The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency related to food storage and labeling.
F0880 - Infection Prevention & Control. The facility failed to follow infection prevention guidelines, with staff not donning appropriate personal protective equipment (PPE) gowns during care of residents with PEG tubes and Foley catheters.
Report Facts
Deficiencies cited: 6
Inspection Report — Feb 20, 2025
Annual Inspection
Date: Feb 20, 2025
Visit Reason
The inspection was an annual recertification survey to assess compliance with regulatory requirements including resident assessments, medication administration, food safety, infection control, and quality assurance.
Findings
The facility was cited for multiple deficiencies including inaccurate coding of resident discharge assessments, medication errors exceeding 5%, improper medication storage, failure to label and discard expired food items, failure to sustain corrective actions in quality assurance, and inadequate infection prevention practices related to PPE use during resident care.
Deficiencies (6)
F0641: The facility failed to accurately code a Minimum Data Set discharge assessment for one resident, resulting in incorrect discharge destination coding.
F0759: The facility failed to ensure medication error rates were below 5%, with three errors observed out of 29 medication administrations affecting two residents.
F0761: The facility failed to ensure medications were safely and securely stored for one resident, with medication left unsecured on a bedside table.
F0812: The facility failed to store food and maintain sanitary practices, with expired, unlabeled, undated, and freezer-burned foods observed in the kitchen.
F0865: The facility's Quality Assurance and Performance Improvement committee failed to sustain corrective actions to prevent recurrence of food storage deficiencies previously cited.
F0880: The facility failed to follow infection prevention guidelines, with staff not wearing gowns during care of residents with PEG tubes and Foley catheters.
Report Facts
Medication administration opportunities: 29
Medication errors: 3
Medication error rate: 10.34
Residents observed during medication pass: 4
Residents affected by medication errors: 2
Kitchen observations: 2
Deficiencies cited for food storage: 2
QAPI deficiencies cited: 1
Care procedures observed for infection prevention: 10
Care procedures with PPE noncompliance: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #2, MDS Coordinator | Confirmed failure to accurately code Resident #48's Discharge MDS assessment | |
| Director of Nursing (DON) | Confirmed MDS coding error and medication administration expectations | |
| Licensed Practical Nurse (LPN) #3 | Observed and interviewed regarding medication errors and storage issues | |
| Certified Dietary Manager (CDM) | Acknowledged food safety deficiencies and described staff training | |
| Dietary Aide (DA) | Described kitchen staff responsibilities for food labeling and monitoring | |
| Administrator | Acknowledged deficiencies and described monitoring practices | |
| Licensed Practical Nurse (LPN) #1 | Observed not wearing gown during PEG tube care | |
| Certified Nurse Aide (CNA) #1 | Observed not wearing gown during Foley catheter care | |
| Infection Preventionist (IP) nurse | Explained PPE requirements and infection prevention policies |
Inspection Report — Feb 18, 2025
Life Safety
Date: Feb 18, 2025
Visit Reason
Survey conducted on 2/18/25 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Dec 8, 2023
Annual Inspection
Date: Dec 8, 2023
Visit Reason
On 12/8/23 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 10/19/23. 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 11/30/23. No deficiencies were cited in this desk review.
Inspection Report — Nov 6, 2023
Life Safety
Date: Nov 6, 2023
Visit Reason
On 11/06/23 the State Agency conducted a desk review of the information related to the annual survey conducted on 10/16/23. The facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The State Agency confirmed the facility had corrected the deficient practice and recommended the facility be placed back in compliance effective 11/06/23.
Inspection Report — Oct 19, 2023
Routine
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pain management, nurse staffing posting, and food safety in the nursing home.
Findings
The facility failed to manage a resident's pain by not administering medication per physician orders, failed to post daily nurse staffing hours for public viewing, and failed to ensure food items were properly dated, labeled, and discarded by expiration dates.
Deficiencies (3)
F 0697: The facility failed to provide safe, appropriate pain management for Resident #6 by not administering Lidocaine patches per physician orders due to supply issues and delayed reorder processes.
F 0732: The facility failed to post daily nurse staffing hours for public viewing on four days reviewed, despite policy requirements.
F 0812: The facility failed to ensure kitchen food items were dated, labeled, and discarded by expiration dates, including expired cranberry cocktail, chocolate syrup, orange juice, Worcestershire sauce, and unlabeled frozen pancakes.
Report Facts
Residents reviewed for pain management: 3
Days staffing posting reviewed: 4
Expired food items observed: 8
Lidocaine patch supply gap: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Lidocaine patch administration and medication room stock. |
| Licensed Practical Nurse #2 | LPN | Interviewed about Lidocaine patch orders and supply. |
| Director of Nursing | DON | Interviewed about medication reorder process, staffing posting, and pain management oversight. |
| Dietary Manager | DM | Interviewed regarding expired food items and food safety responsibilities. |
| CNA Team Leader #1 | CNA Team Leader | Interviewed about awareness of staffing hours posting. |
| Assistant Administrator | Assistant Administrator | Interviewed about staffing posting requirements and food safety. |
Inspection Report — Oct 19, 2023
Annual Inspection
Date: Oct 19, 2023
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/16/2023 through 10/19/2023. During the survey, the facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M815.
Findings
M815 - The facility failed to ensure items in the kitchen refrigerators, freezers, and dry storage room were dated, labeled, and discarded by the expiration date during one of three dietary observations. Several expired and improperly labeled food items were found, posing a risk to all residents receiving meals prepared by the dietary department.
Deficiencies (1)
M815 - Safe Food Handling Procedures. The facility failed to ensure items in the kitchen refrigerators, freezers, and dry storage room were dated, labeled, and discarded by the expiration date for one of three dietary observations, potentially affecting all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 19, 2023
Annual Inspection
Date: Oct 19, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/16/2023 through 10/19/2023. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F697, F732, and F812.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in pain management, nurse staffing information posting, and food procurement and storage practices.
Deficiencies (3)
F0697 - Pain Management. The facility failed to manage a resident's pain by not administering medication per physician orders for one of three residents reviewed for pain, resulting in a delay in providing the prescribed Lidocaine patch for five days.
F0732 - Posted Nurse Staffing Information. The facility failed to post the daily staffing hours for public viewing on four days reviewed, with staffing boards missing actual hours worked by licensed and unlicensed personnel.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to ensure items in the kitchen refrigerators, freezers, and dry storage room were dated, labeled, and discarded by the expiration date, including expired beverages and unlabeled frozen pancakes.
Report Facts
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Oct 16, 2023
Life Safety
Date: Oct 16, 2023
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found deficient for failing to properly document records of testing the generator annually as required by NFPA standards. This deficiency had the potential to affect the entire facility on the day of the survey.
Deficiencies (1)
K0918 - The facility failed to properly document records of testing the generator annually as required by NFPA 110 and NFPA 99, which could affect the entire facility.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 16, 2023
Date: Oct 16, 2023
Visit Reason
The document does not explicitly state the survey type in the Initial Comments block; only the survey completion date is given.
Findings
The facility failed to properly document records of testing the generator annually as required, which could affect the entire facility.
Deficiencies (1)
M1245 - The facility failed to properly document records of testing the generator annually as directed by NFPA standards, potentially affecting the entire facility.
Report Facts
Deficiencies cited: 1
Inspection Report — May 18, 2022
Complaint Investigation
Date: May 18, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #18302, at the facility on 5/18/22. The complaint involved dietary, physician and RR not notified resident change of condition.
Complaint Details
CI MS#18302 - Complaint of dietary, physician and RR not notified resident change of condition was not substantiated; no deficiencies cited.
Findings
The SA did not substantiate the complaint and determined the facility was in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm. There were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — May 18, 2022
Complaint Investigation
Date: May 18, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #18302 at the facility on 5/18/22.
Complaint Details
Complaint MS #18302 alleged dietary, physician and responsible representative were not notified of changes; the complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — May 18, 2022
Routine
Date: May 18, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 5/18/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Apr 4, 2022
Routine
Date: Apr 4, 2022
Visit Reason
Based on the content and tags, this was a routine COVID-19 focused survey assessing the facility's reporting to the 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, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network. The facility failed to report complete COVID-19 information to the CDC's NHSN during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 9, 2021
Annual Inspection
Date: Nov 9, 2021
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual survey conducted on 9/10/21. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found to be back in compliance effective 10/27/21 with no deficiencies cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 10, 2021
Life Safety
Date: Sep 10, 2021
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found deficient for failing to select, install, inspect, and maintain portable fire extinguishers in accordance with NFPA standards. All fire extinguishers were overdue for their 12-year inspection, dated 2007, affecting the entire facility.
Deficiencies (1)
K0355 - Portable fire extinguishers were overdue for the required 12-year inspection, with all extinguishers dated 2007, failing to meet NFPA 101 and NFPA 10 standards.
Report Facts
Deficiencies cited: 1
Inspection Report — Sep 10, 2021
Routine
Date: Sep 10, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including proper use of Bi-level Positive Airway Pressure (BIPAP) machines, catheter care, and infection control practices.
Findings
The facility failed to correctly code the Minimum Data Set (MDS) for BIPAP use and failed to ensure Resident #9 received ordered BIPAP therapy. The facility also failed to follow comprehensive care plans for catheter care for Resident #11 and failed to prevent possible infection spread during catheter and incontinent care for multiple residents.
Deficiencies (5)
F0636: The facility failed to code the MDS correctly regarding BIPAP use for Resident #9 and failed to ensure the resident received BIPAP therapy as ordered.
F0656: The facility failed to develop and implement a complete care plan by not securing a Foley catheter tube to Resident #11's leg and not ensuring Resident #9 received BIPAP respiratory therapy as ordered.
F0690: The facility failed to provide appropriate catheter care by not anchoring the Foley catheter tube securely and not securing the tubing with a catheter leg strap for Resident #11.
F0695: The facility failed to provide safe and appropriate respiratory care by not ensuring Resident #9 received necessary BIPAP services as ordered.
F0880: The facility failed to prevent possible infection spread during catheter and incontinent care observations for Residents #5, #11, and #144 due to improper hand hygiene, failure to use barriers, and failure to change gloves appropriately.
Report Facts
BIPAP use recorded: 6
BIPAP refusals recorded: 10
BIMS score: 15
BIMS score: 7
BIMS score: 3
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Admission Nurse | Reported Resident #9's complaints about BIPAP not fitting correctly and notified the Director of Nursing. |
| Director of Nursing | DON | Discussed Resident #9's BIPAP issues and care plan compliance; confirmed CNA #1's failure to secure catheter tubing for Resident #11. |
| CNA #1 | Certified Nursing Assistant | Failed to secure catheter tubing and leg strap for Resident #11 during catheter care. |
| CNA #2 | Certified Nursing Assistant | Failed to wash hands and change gloves properly during incontinent care for Resident #5. |
| CNA #3 | Certified Nursing Assistant | Failed to use barrier and change gloves properly during catheter care for Resident #144. |
| Assistant Director of Nurses | ADON | Explained facility procedures for refusal of oxygen and medication; commented on infection control issues. |
| RN #1 | Registered Nurse | Confirmed CNA #1's failure to follow care plan and infection control procedures. |
| RN #2 | Registered Nurse | Explained expectations for following care plans and physician orders. |
| Physician #1 | Physician | Provided medical oversight for Resident #9 and was unaware of BIPAP non-use. |
Inspection Report — Sep 10, 2021
Annual Inspection
Date: Sep 10, 2021
Visit Reason
An annual survey and Complaint Investigations (CI) MS#16634, CI MS#17888, and CI MS#17870 was conducted by the State Agency (SA) from 9/7/2021 through 9/10/2021. The facility was found to not be in compliance with the requirements of participation in Medicare and Medicaid. The SA substantiated the complaints for CI MS#16634, and CI MS#17870 related to abuse and visitation and cited F563, F609, and F610. The SA did not substantiate CI MS#17888 related to Resident/Patient Treatment with dignity and respect, Rehabilitation, Quality of care and treatment, and injury of unknown origin. The SA cited F636, F656, F690, F695 and F880 in the annual survey.
Complaint Details
Complaint Investigations (CI) MS#16634 and CI MS#17870 were substantiated related to abuse and visitation, with deficiencies cited at F563, F609, and F610. CI MS#17888 was not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to accurately code the Minimum Data Set (MDS) for Bi-level Positive Airway Pressure (BIPAP) use, failure to follow comprehensive care plans for securing Foley catheter tubing and providing respiratory therapy, failure to ensure residents received ordered respiratory care, and failure to prevent possible spread of infection during catheter and incontinent care.
Deficiencies (5)
F0636 - The facility failed to accurately code the Minimum Data Set (MDS) regarding Bi-level Positive Airway Pressure (BIPAP) for one resident, Resident #9, who did not use the BIPAP as ordered due to improper settings and lack of staff knowledge.
F0656 - The facility failed to follow the comprehensive care plan by not securing a Foley catheter tube to Resident #11's leg and by not ensuring Resident #9 received Bi-level Positive Airway Pressure (BIPAP) respiratory therapy as ordered.
F0690 - The facility failed to anchor a Foley catheter tube securely and failed to secure the tubing with a catheter leg strap for Resident #11, risking friction and trauma to the meatus.
F0695 - The facility failed to ensure Resident #9 received necessary respiratory care with the ordered Bi-level Positive Airway Pressure (BIPAP) machine, as the resident did not wear the BIPAP due to improper settings and lack of staff knowledge, and the physician was not notified timely.
F0880 - The facility failed to prevent the possible spread of infection during catheter and incontinent care observations for Residents #5, #11, and #144, including failure to use barriers, improper hand hygiene, and failure to change gloves appropriately.
Report Facts
Deficiencies cited: 9
Inspection Report — Dec 21, 2020
Routine
Date: Dec 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency from 12/20/20 through 12/21/20.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19 and the requirements for participation in Medicare and Medicaid.
Inspection Report — Dec 21, 2020
Routine
Date: Dec 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) from 12/20/20 through 12/21/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Jun 10, 2020
Routine
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on June 9-10th, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 10, 2020
Routine
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on June 9-10, 2020. The facility was not in substantial compliance with infection control requirements during the COVID-19 pandemic.
Findings
F0880 - Infection Prevention & Control. The facility failed to ensure staff cleaned and disinfected a blood pressure machine and thermometer between resident use for six sampled residents, risking the spread of infection.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to ensure staff cleaned and disinfected a blood pressure machine and thermometer between resident use for six sampled residents, risking the spread of infection.
Report Facts
Deficiencies cited: 1
Inspection Report — May 28, 2020
Routine
Date: May 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/28/20.
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 — Apr 25, 2019
Annual Inspection
Date: Apr 25, 2019
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 4/22/19 to 4/25/19. During the survey, the SA determined that the facility was in compliance with Medicare and Medicaid regulations for participation.
Findings
The facility was found in compliance with Medicare and Medicaid regulations. One deficiency was cited related to the emergency power system generator failing to transfer power within the required 10 seconds.
Deficiencies (1)
K0918 - The facility failed to provide a generator that transferred power to the facility within 10 seconds as required by NFPA 110; the generator transferred power in 13.13 seconds during testing on April 25, 2019.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 25, 2019
Annual Inspection
Date: Apr 25, 2019
Visit Reason
The State Agency (SA) determined during an annual recertification survey conducted on 4/25/19, the facility was in compliance for State Licensure requirements.
Findings
The facility was found in compliance with no deficiencies cited except for a generator transfer time issue noted in the Life Safety Code section.
Deficiencies (1)
M1245 - The facility failed to provide a generator that transfers power to the facility within 10 seconds as required by NFPA 110; the generator transferred power in 13.13 seconds during testing on April 25, 2019.
Report Facts
Deficiencies cited: 1
3 CMS Surveys
CMS Survey — Sep 10, 2021
Sep 10, 2021
CMS Survey — Oct 19, 2023
Oct 19, 2023
CMS Survey — Feb 20, 2025
Feb 20, 2025
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