Edgewood Health & Rehabilitation
205 Byram Parkway, Byram, MS 39272 · For profit - Corporation · 119 certified beds · (601) 362-5394 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602, F0609, F0610) — most recent Mar 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 6 immediate-jeopardy problems — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (47) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $148,438 in federal fines (most recent 2026-03-02)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
- about 27% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.0% | 20.5% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.2% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.8% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.7% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 1.2% | 0.2% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 0.7% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.1% | 19.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.4% | 23.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.3% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 6.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 19.2% | 20.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.3% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 2.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 61.2% | 84.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.0% | 27.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.9% | 15.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.76 | 2.43 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.55 | 2.86 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 132 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 50 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 51.5%CMS range 41.3–59.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 8.6–16.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 62.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 88.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 77.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 4.1–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 119 beds and averages 108.6 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.36 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.67 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.33 hrs/resident/day on weekends vs 5.78 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
47 citations, most serious first. The 26 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-03-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review and interviews, the facility failed to ensure the residents' right to be free from abuse and failed to protect Resident #1 from abusive and degrading treatment by Certified Nurse Aide (CNA) #1 and CNA #2 during the provision of care on the evening of 2/10/26. The abusive conduct included the use of disparaging, derogatory, and humiliating language and intimidation toward Resident #1 while the resident requested assistance and complained of pain during care for one (1) of four (4) sampled residents. Resident #1.The State Agency (SA) identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/26/26. The IJ began on 2/14/26, when the facility failed to protect residents from abuse, failed to report alleged abuse timely, failed to promptly investigate allegations of abuse, and Administration failed to implement and enforce the facility's abuse policies.The facility's failure to report, protect, and investigate abuse placed all residents residing in the facility at risk in a situation likely to cause serious injury, serious harm,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2026-03-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review and interviews, the facility failed to report an allegation of verbal abuse of a resident within the required timeframe of two (2) hours after the allegation was reported to facility staff. The allegation was reported to the facility on 2/14/26 at approximately 8:40 AM but was not reported to the State Agency until 2/16/26 at 11:30 AM. This was for one (1) of four (4) sampled residents. Resident #1.This failure resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 02/14/26 and placed Resident #1 and all other residents in a situation that was likely to cause serious harm, serious impairment, serious injury or death.The IJ and SQC existed at:CFR 483.12(c)(1)(4) Reporting of Alleged ViolationsScope and Severity (S/S) JThe SA notified the facility Administrator of the Immediate Jeopardy on 02/26/26 at 4:05 PM and provided the IJ template.The facility submitted an acceptable removal plan on 02/27/26 in which the facility alleged all corrective actions were completed on 02/27/26 and the IJ was removed on 02/28/26.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2026-03-02 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review, and interviews, the facility failed to thoroughly investigate an allegation of abuse in a timely manner to prevent further potential abuse. The facility failed to initiate a prompt and thorough investigation after an allegation of verbal abuse of Resident #1 was reported on 2/14/26. The facility did not immediately interview staff or residents, did not initiate protective interventions, and delayed investigative actions until 2/16/26. This deficient practice affected one (1) of three (3) reviewed incidents with documented indications of possible abuse. Resident #1.The facility's failure to initiate a timely investigation and implement protective measures created the likelihood of continued abuse of Resident #1 and other residents and placed them in a situation that was likely to cause serious harm, serious injury, serious impairment or death. Staff confirmed that the allegation involved demeaning and abusive language toward Resident #1, yet no interviews, resident assessments, or protective interventions were implemented on 2/14/26 when the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2026-03-02 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review, and interviews, the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure administrative leadership implemented timely actions to respond to and manage an allegation of verbal abuse involving Resident #1. The Administrator was notified of the allegation on 2/14/26 at approximately 9:00 AM but failed to ensure the allegation was reported within required timeframes, failed to ensure the alleged perpetrator was immediately removed from resident contact, and failed to ensure a prompt investigation was initiated. This deficient practice affected one (1) of four (4) sampled residents. Resident #1.The facility's failure to provide effective administrative oversight resulted in delays in reporting the allegation to the State Agency (SA) and delays in initiating investigative actions. The alleged perpetrator, Certified Nurse Aide (CNA) # 2, continued to work in the facility after the allegation was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2025-06-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 6/10/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of seven (7), was let out of the building by a lawn service worker. She exited the facility in her wheelchair unnoticed and was last seen inside the facility at 11:05 AM. She was found at 11:08 AM by a visitor walking into the facility in the facility's parking lot, approximately 145 feet from the front door of the building. The facility's failure to provide supervision and ensure environmental safety put Resident #1 and other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2024-06-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and facility policy review, the facility failed to ensure a care plan was implemented to prevent a resident's access to a medication cart, when a resident, without supervision, opened an unlocked medication cart and drank Lactulose liquid for one (1) of nine (9) sampled residents. Resident #1 The facility's failure to implement care plan interventions placed this resident and other cognitively impaired residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 6/4/24, when Resident #1 opened an unlocked and unattended medication cart and took a bottle of Lactulose and drank from the bottle. The facility Administrator was notified of the IJ on 6/20/24 at 4:25 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 6/21/24, in which they alleged all corrective actions to remove the IJ were completed on 6/21/24 and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2024-06-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review and facility policy review the facility failed to provide an environment free from accident/hazards and supervision, as evidenced by leaving a medication cart unlocked and unattended, allowing a resident to remove and ingest a medication from the cart for one (1) of nine (9) sampled residents. Resident #1 The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 6/4/24, when Resident #1 opened an unlocked and unattended medication cart and took a bottle of Lactulose and drank from the bottle. The facility's failure to ensure the resident was protected from accident/hazards placed this resident and other residents at risk and in a situation likely to cause serious injury, serious harm, serious impairment or death. The facility Administrator was notified of the IJ and SQC on 6/20/24 at 4:25 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 6/21/24, in which they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-10-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review the facility failed to ensure that the comprehensive person-centered care plan was implemented for one (1) of four (4) sampled residents (Resident #1).Findings included:Record review of the facility policy titled, Care Plans-Comprehensive dated 10/2016 revealed .Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s). Record review of the Care Plan Report for Resident #1 revealed Focus: Resident requires assistance with ADL's (activities of daily living) r/t (related to) muscle weakness/QUATDRIPLEGIA/PARESIS.Interventions.Requires the use of the total mechanical lift X 2 (with two) nursing staff members.Record review of the Care Plan Report date initiated 12/6/23 and revised on 10/20/25, revealed Focus: Resident is at risk for falls and fall related injuries. Interventions. Provide assistance as needed for transfers. 10/17/25 Resident returned from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-10-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure adequate supervision and the implementation of safety interventions to prevent accidents for two (2) of four (4) sampled residents (Resident #1 and Resident #2)Findings included:Record review of the facility policy titled, MODIFIED LIFTING POLICY with a revision date of September 2025 revealed .Use of a mechanical lift requires two (2) nursing assistants or nurses to perform the procedure each time that it is used.Record review of the facility policy titled, TRANSPORT OUT OF FACILITY dated 7/2008 (July 2008) revealed the policy did not address requirements, training for qualifications for staff who performed transportation of residents. Resident #1Record review of the Lift Determination for Resident Lift/Transfer Assistance for Resident #1 dated 9/23/25 revealed the facility assessed that the resident was dependent for surface-to-surface transfers, and that conditions likely to affect transfer techniques included colostomy, contractures/spasms, paralysis and pressure ulcers and that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-08-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to notify the Physician or the Resident Representative (RR) when a resident experienced pain to her right knee after a resident transfer which resulted in a femoral fracture that was diagnosed the following day for one (1) of ten (10) sampled residents that require a mechanical lift for transfers. (Resident #5) Findings Include: A review of the facility's policy Resident Change in Condition revised 2016, revealed, .It is the policy of this facility to promptly notify the resident, his or her attending physician, and the resident representative (RR) of changes in the resident's condition .Procedure 1. The Charge Nurse will notify the resident's attending physician when: a. The resident is involved in any accident or incident that results in an injury .b. There is a significant change in the resident's physical, mental or psychosocial status .g. Deemed necessary or appropriate in the best interest of the resident. 2. Unless otherwise instructed by the resident, the charge nurse will notify the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-08-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to pain when Resident #5 yelled out in pain during a transfer for one (1) of 23 residents reviewed for care plans. (Resident #5) Findings Include: A review of the facility's Following the Care Plan Policy, dated 1/2011, revealed, .It is the Policy of this facility to follow a written and approved care plan for each resident. All employees will be .required to follow the care plan. Procedure .All employees will follow the written care plan that is developed in order to assure the residents needs are met. A record review of the Comprehensive Care Plan with an initiation date of 6/2/23 revealed Focus: Resident is at risk for pain .Interventions initiated on 6/2/2023 .Document type, location and severity of pain .Give medications as ordered . A record review of the facility's investigation summary dated 7/6/24 and a follow up investigation dated 7/11/24 as reported to the State Agency revealed that on the morning of 7/3/24, Resident #5 complained…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards when facility staff were aware a resident who was care planned for a mechanical lift was sliding from a wheelchair and the staff detached the lift pad from the mechanical lift, causing the resident to further slide and be manually transferred which resulted in a right femur fracture for one (1) of ten (10) sampled residents that required transfers via mechanical lift. (Resident #5) Findings Include: A review of the facility's Responsibility for Accident/Incident Report Policy dated [DATE] revealed, .It is the policy of this facility for all Incidents and Accidents involving resident's to be investigated immediately upon knowledge of the incident. Procedure .Procedure .They are to document on the proper forms and notify the Administrator and/or DON (Director of Nursing) immediately when there is an injury . A record review of the facility's investigation summary dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-08-01 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to ensure pain management was provided to a resident who complained of pain after a manual transfer from her wheelchair to the bed and was subsequently diagnosed with a femoral fracture for one (1) of 23 residents reviewed for pain, Resident #5. Findings Include: A record review of the facility's policy Pain Assessment/Management revised 09/10, revealed, It is the policy of this facility to provide guidelines in the identification and treatment of the residents at risk of acute and chronic pain. Each resident's pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .pain will be assessed and recorded on the medication administration record. The nurse will document the type of nonverbal or verbal pain the resident is experiencing when documenting the reason the medication is being given. The nurse will also document the intensity of the pain each time a PRN pain medication is given using the rating scale . A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-04-03 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to timely manage and treat complaints of pain for two (2) of four (4) sampled residents, when the unit the residents resided on did not have a licensed nurse to assess, monitor, or treat complaints of pain from approximately 7:00 PM on 3/22/24 until approximately 1:47 AM on 3/23/24. Residents #2 and #4 Findings Include: Record review of the facility policy titled, Pain Assessment/Management, revised 9/10, revealed, It is the policy of this facility to provide guidelines in the identification and treatment of residents at risk for acute and chronic pain. Each residents pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .Staff members providing direct care .will use an interdisciplinary approach observing pain symptoms in the resident and report it to the nurse. If possible, the nurse will discuss with the resident the severity and quality of pain using the pain reference scale. This will be documented on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-07-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review and facility policy review, the facility failed to revise a comprehensive care plan regarding interventions to prevent a dependent resident from falling for one (1) of three (3) residents reviewed for falls. Resident #98. Findings include: Review of the facility's policy, titled Care Plans-Comprehensive, dated 10/2016 revealed, An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly . Record review of the Fall Assessment for Resident #98, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-07-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to provide care in a manner to protect vulnerable residents from falls resulting in injury for one (1) of three (3) residents reviewed for falls. Resident #98 Findings include: Review of the facility's policy, Fall Risk Documentation Policy and Procedure, revised 5/2005 revealed, It is the policy of this facility to evaluate and provide least restrictive intervention when a resident is a risk for falls. Upon Admission, Quarterly, and as needed the Fall Risk documentation form will be completed for each resident. The resident will be scored in eight (8) areas. A total score of these areas will determine at what level of risk the resident is. A score of 10 or greater will place the resident in the High-Risk category. Prevention protocol will be initiated immediately and documented on the care plan. Review of the facility's protocol, Protocol for Residents Who Are at Risk for Falls, revised 5/2001 revealed, 1. Residents identified as being at high risk for fall shall be place on the fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and facility policy review the facility failed to provide assistance with turning and repositioning per standards of care for two (2) of nine (9) sampled residents who required assistance with activities of daily living (ADL) and repositioning. Resident #1 and Resident #2. Findings include: Record review of the facility policy titled ADL CARE POLICY dated 8/23 (August 2023) revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis, while attaining or maintaining the residence of highest, practicable, physical, mental and social well-being.Resident #1On 1/12/26 at 9:30 AM observation revealed Resident #1 was resting in bed on her back with head of bed elevated. She had a family member (niece) seated in a chair next to her bed.On 1/12/26 at 2:00 PM, during an interview the family member that was sitting with Resident #1 revealed she had not left the resident's room since she arrived and Resident #1 had not been turned or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review the facility failed to ensure accurate labeling of medication for one (1) of three (3) medication carts. The 400 Hall Medication Cart. Findings include:Record review of the facility policy titled, Medical SUPPLY STORAGE POLICY dated 3/2011 (March 2011) revealed the policy did not address storage of one medication in another's package.Record review of the MEDICATION ERROR REPORT signed by the DON and dated 12/29/25 revealed, .Individual Restasis vial were inside of nebulizer box.family reported wrong vial was brought into the room .On 1/12/26 at 4:45 PM, during an interview the Administrator revealed he expected the nurses to maintain accurate storage of medications in a manner that would provide for safe administration of medications. He stated that storing one medication in the box of a different medication could lead to administration of the wrong medication and cause complications for the resident.On 1/12/26 at 5:00 PM, during an interview the Director of Nurses (DON) confirmed that on 12/29/25 she had been notified by Resident #1's family…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-29 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, record review, and facility policy review the facility failed to ensure staff who perform resident transportation possessed and demonstrated the competencies necessary to carry out their responsibilities safely one (1) of four (4) residents dependent on the facility for transportation, Resident #2. Findings included:Record review of the facility policy titled, TRANSPORT OUT OF FACILITY dated 7/2008 (July 2008) revealed the policy did not address requirements, training for qualifications for staff who performed transportation of residents. Record review of the Incident Report for Resident #2 dated 10/22/25 revealed LPN #1 documented, STAFF REPORTED THAT WHILE THE RESIDENT WAS SITTING IN THE WHEELCHAIR IN THE VAN, (FACILITY TRANSPORTATION) THE WHEELCHAIR MOVED BACK AND TILTED.STAFF ASSISTED REISDENT AND PLACED WHEELCHAIR IN A STABLE POSITION. At 3:10 PM on 10/28/25, during a telephone interview, the Resident Representative (RR) for Resident #2 revealed she confirmed that facility staff had notified her that Resident #2 had an incident on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint: MS #29210 Based on record review, interview, and facility policy review, the facility failed to develop and revise a comprehensive care plan in accordance with physician orders and professional standards for one (1) of three (3) residents reviewed for respiratory equipment (Resident #2). Specifically, the facility failed to update the resident's care plan to reflect a new physician order dated 1/31/25 for an auto-adjusting -(continuous positive airway pressure) C-Pap at 8-18 cm (centimeter) of H20 (water), with modem setup, and the interdisciplinary team did not review or implement updated interventions related to the resident's new therapy. Findings included: A review of the facility's Care Plans-Comprehensive, revised on 10/2016, revealed, .An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident medical, nursing, mental and psychological needs is developed for each resident . A record review of the admission Record revealed the facility admitted Resident #2 on 7/20/2020 with current diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint MS #29210 Based on record review, interview, and facility policy review, the facility failed to ensure services were provided and documented according to professional standards for one (1) of three (3) sampled residents receiving individual Continuous Positive Airway Pressure (C-Pap). Resident #2. Specifically, the facility failed to follow and transcribe a physician's order dated 1/31/25 for a new C-Pap machine, until 5/28/25. Findings included: A review of the facility's policy titled, Transcribing Physician Orders, revised 2/27/2012, revealed, .It is the policy of this facility to transcribe and follow the attending physicians orders as written with order clarification obtained when needed . Resident #2 A record review of the admission Record revealed the facility admitted Resident #2 on 7/20/2020 with current diagnoses including bipolar disorder. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated he is moderately impaired. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from abuse for two (2) of seven (7) sampled residents reviewed, Resident #1 and Resident #2. Findings include: Record review of the facility policy titled Preventing Resident Abuse, with a revision date of 8/16/2016, revealed .1. The facility's goal is to achieve and maintain an abuse-free environment .3. Residents have the right to be free from all forms of abuse. Abuse includes conduct that causes or has the potential to cause the resident to experience humiliation, fear, shame, agitation, or degradation. Resident #1 Record review of the facility's Final Investigation dated 2/22/25-2/23/25 revealed the facility's documentation stated that on 2/24/25, the roommate of Resident #1 (Resident #6) reported to the Director of Nursing (DON) and Social Services Director (SSD) that on the night of 2/22/25 or early morning of 2/23/25, she heard Resident #1 say, Stop hitting me, while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions on the Activities of Daily Living (ADL) care plan for Resident #7 when the resident's drink was left unopened, her cereal was served dry, and her utensils were placed out of reach during the evening meal on 3/20/25 for one (1) of seven (7) sampled residents reviewed. Resident #7. Findings include: Record review of the Care Plan dated 7/07/24 for Resident #7 revealed a focus of Resident requires assistance with ADLs related to muscle weakness and diagnosis of Alzheimer's Disease .Interventions .Provide assistance as needed for ADLs .Resident able to feed self with tray set-up but does require nursing staff to assist with feeding at times due to visual impairment On 3/20/25 at 5:30 PM, during a dining observation and interview, Resident #7 and her roommate were alone in their room. Resident #7 was sitting in bed with her supper tray on her over-the-bed table. She had her soda can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to provide appropriate services to maintain the ability to carry out activities of daily living (dining/eating) when the resident's drink was left unopened and her utensils were left out of reach during the evening meal on 3/19/25, which prevented her from feeding herself for one (1) of seven (7) sampled residents reviewed. Resident #7 Findings include: Record review of the facility policy titled, Meal Assistance and Assistance Policy, dated May 2024, revealed Policy . Compliance Guidelines . 5. Check the tray before serving it to the resident to be sure that it is correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow . Arrange the dishes and silverware so that the resident can reach them easily . 8. Open all cartons and remove all lids from items on the tray. Give the napkin to the resident . 17. Encourage the resident to participate with his or her meal as much as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-20 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to provide a meal that was palatable in appearance when the facility posted Club Sandwich and French Fries on the menu for the evening meal on 3/19/25 and the sandwiches served were not palatable in appearance and did not match the facility's recipe for two (2) of seven (7) sampled residents reviewed. Resident #3 and Resident #4. Findings include: Record review of the facility policy titled MENUS, dated 4/21/22, revealed the policy stated: Policy . Foods will be served as planned on the menu unless there is a legitimate and extenuating circumstance . Standardized recipes are available for all items included on the cycle menu. Computerized recipes may be used. Record review of the posted menu for the evening meal on 3/19/25 revealed the menu listed Club Sandwich, Potato Chips, Cookie of Choice, Fruit of Choice, Iced Tea, and Milk. Record review of the Menu Calendar Report, Week 4, revealed that the Wednesday dinner menu…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and policy review, the facility failed to ensure the written contents of the notice of discharge included all of the requirements for a facility-initiated discharge for one (1) of two (2) Residents reviewed. (Resident #1) Findings Include: A review of the facility's policy titled, Transfers and Documentation, dated 02/2024, revealed Transfers may occur within the facility for the following reasons: 1. The needs of the resident cannot be met in the section of the facility in which he/she is residing. 2. The resident threatens the safety of himself/herself or the safety of other residents in the facility. 3. The health or other residents is endangered. 4. The resident and/or resident representative requests a transfer made . During an interview on 11/25/24 at 2:48 PM, Resident #1's brother stated the discharge letter was dated 9/6/24 and was received by certified mail on 9/18/24. He stated he felt like there should have been more communication between the facility and family…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · Fcited before2024-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy review, the facility failed to store food and use sanitary practices in accordance with professional standards for food service safety related to unlabeled food items, food items exposed, overly ripe produce, improperly stored foods, and contaminated dry bin items for one (1) of two (2) kitchen observations. This has the potential to affect all residents who receive meals from the dietary department. Findings Include: A review of the facility's policy titled Food Storage Labeling, dated 3/24, revealed, . All food items that are not in their original containers must be labeled with the common name of the food and the use-by date Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed the manufacturer use-by date or expiration date . A review of the facility's policy titled Storage of Canned and Dry Food, dated 11/23, revealed, .Opened packages are stored in tightly covered containers intended for food that are durable, leak proof, and can be tightly sealed or covered and labeled . Dry food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-01 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interviews, the facility failed to ensure a resident was free from physical restraints, as evidenced by not completing an assessment and evaluation for an upper body harness vest and by not ensuring the upper body vest was the least restrictive device for one (1) of one (1) sampled residents for restraints. Resident #88 Findings Included: A record review of the facility's policy titled Physical Restraint, dated 2/20/12, revealed .Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully .1. Restraints will only be used after alternatives have been tried unsuccessfully, and only with informed consent from the resident, physician, and/or responsible party . A record review of the facility's policy titled, Restraint Decision Policy, dated 10/2016, revealed, Policy: It is the policy of this facility to provide the least restrictive, restraint-free environment for our residents .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and facility policy review, the facility failed accommodate the needs of a resident, as evidenced by, leaving a resident who was dependent on staff for eating, unassisted and unfed during a meal, for one (1) of 23 sampled residents. Resident #70. Findings Include: A review of the facility's policy titled Residents Rights dated 1/24/22 revealed, Policy Statement .Residents' rights policies and procedures shall ensure that each resident admitted to the center .Policy Interpretation and Implementation .9. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs . On 07/29/24 at 12:44 PM, an observation with Resident #70 revealed she was sitting up in her electric wheelchair. Both of her arms were contracted down by her sides. There was a blow call light to the right side of Resident #70. The resident had a mouth stylus pen that she was using to scroll and type on her phone. In an interview, Resident #70 indicated that Certified Nursing Assistant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper storage of respiratory equipment as evidenced by tubing not dated or bagged when not in use for one (1) of one (1) resident sampled for respiratory care. Resident #88 Findings Include: A record review of the facility policy titled Nebulizer and Oxygen Tubing Storage Policy, dated April 2007, revealed, POLICY It was the policy of the facility to decrease the risk of potential and/or direct exposure to infectious diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment . The facility will replace all respiratory tubing weekly. These tubings will be dated and stored in a dated plastic bag when not in use. The plastic bags will also be changed out weekly . A record review of Resident #88's Order Summary Report with active orders as of 7/30/24, revealed an order 3/5/24 O2 (oxygen) at 2 (two) liters per nasal cannula PRN (as needed) for SOB (shortness of breath). An additional order dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-01 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff and resident interviews, record review, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee as evidenced by one (1) re-cited deficiency originally cited in July 2023 on an annual recertification survey. Findings Include: A record review of the facility policy Quality Assurance and Performance Improvement (QAPI) Plan of Action dated 4/1/2021 revealed on page seven and page eight: Quality Assurance Program Tools: This facility's QAPI systems and processes are maintained within an ongoing program that is dynamically designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and resolve identified problems .Focus Indicators: the QAPI provides comprehensive oversight but maintains a priority focus which follows indicators that are high risk, problem-prone, and low volume with the potential for undesirable outcomes such as .IV. Restraint Management . F604: During this recertification survey, the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff and Resident Representative (RR) interview, record review and facility policy review the facility failed to notify the RR/family of a severely cognitively impaired resident of a change in the resident's condition, for one (1) of nine (9) sampled residents. Resident #6 Findings include: Record review of the facility policy titled, Notification of Family/Resident Representative, with revision date 10/2016, revealed, Policy: It is the policy of this facility to notify family or resident representative of all services provided by this facility. This included changes in a resident's condition or status. The physician, family member or resident representative will be notified of the change . Record review of the Resident Grievance Investigation Form, dated 6/03/24 revealed . RR was upset .with regards to old, scattered scratches on his chest area .The scratches were documented in the body audit, but the nurse forgot to call the RR . On 6/18/24 at 1:18 PM, during an interview with the DON, she stated that she had pitched in to help the nurses on 5/27/24, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure an allegation of resident-to-resident non-consensual sexual contact was reported to the State Agency (SA) for two (2) of nine (9) sampled residents. Residents #3 and #4 Findings included: Record review of the facility policy titled, Abuse Policy and Procedure dated 3/21/2022, revealed, Policy Statement: Each resident of this facility has the right to be free from verbal, sexual .mental abuse . Residents are not to be subjected to abuse by anyone. This includes .other residents . Abuse Policy Employee Responsibility .7. Any alleged incident REPORTED must be investigated and REPORTED to the state within 24 hours of knowledge of such alleged incident. In addition, a written report must be submitted by Registered Mail within 72 hours. On 6/17/24 at 12:00 PM, an interview with License Practical Nurse (LPN) #1 revealed that on 6/09/24 she was assigned to the care of Residents #2, #3 and #4. She stated that at approximately 12:15 PM, (after lunch) she observed in the dining…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure the environment was free from accident hazards and residents received adequate supervision to prevent a resident from ingesting a cleaning solution retrieved from an unsecured housekeeping cart for one (1) of two (2) residents reviewed with wandering behaviors. (Resident #1) Findings include: Record review of the facility policy titled, Hazardous Chemical Storage, dated 10/2003, revealed, Policy: Environmental services shall maintain all hazardous chemicals in a safe, clean, and locked location when not in use. All hazardous chemicals shall be in control of facility personnel while being used. Procedure: 1. Hazardous chemicals will be maintained in a locked storage area at all times. 2. Hazardous chemicals in use by environmental services shall remain under direct control by facility personnel while in common traffic areas. 3. Hazardous chemicals placed on environmental services cleaning carts shall be locked in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-06 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility investigation and facility policy review, the facility failed to protect a resident from misappropriation of funds for one (1) of three (3) residents sampled. Resident #1 Findings include: A review of the facility's policy, Abuse Policy and Procedure, dated 1/24/22, revealed Policy Statement: Each resident of this facility has the right to be free from . misappropriation of resident property. Definitions of Abuse: 7. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . Record review of the facility's investigation revealed it was reported to the facility on [DATE] that the Social Service Director #1 had not provided a resident with the money he requested on two separate occasions on 12/13/23 and 12/15/23. The Administrator investigated the claim and based on video footage, interviews with the resident and Social Service Director…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-27 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure that the resident or the resident's representative received education regarding influenza and pneumonia immunizations and were given the opportunity to receive or refuse the immunizations for 20 of 25 residents reviewed for immunizations.Resident #8, Resident #16, Resident #17, Resident #19, Resident #26, Resident #28, Resident #31, Resident #33, Resident #41, Resident #44, Resident #48, Resident #49, Resident #55, Resident #62, Resident #70, Resident #71, Resident #85, Resident #98, Resident #102, Resident #304 Findings include: Review of the facility's policy titled Immunization of Residents, revised 10/2015, revealed It is the policy of this facility to provide immunizations of residents against preventable disease within the facility. 1. Upon admission to the facility, permission must be obtained from the resident or representative to administer or withhold the Pneumonia vaccine per MD (Medical Doctor) Orders and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure a resident's privacy as evidenced by posting of clinical care signage on the resident's wall for one (1) of 22 residents reviewed in sample. Resident #75. Findings Include: Record review of policy titled, Resident Room Postings, dated 2/2020, revealed, It is the policy of this facility to support a resident's right to personal privacy and confidentiality in all aspects of care and services, to include personal and medical record. The policy goes on to read that 4. Resident room postings will only be allowed if resident or resident's representative request posting at the bedside or if used as a visual safety reminders. On 07/24/23 at 10:26 AM, observation revealed signage related to clinical status and posted over the resident's bed that read to please assist resident with all meals and rotate resident every 2 hour, keep off trochanter. On 07/25/23 at 12:32 PM, observation revealed signs remain posted over resident's bed. On 07/26/23 at 01:07 PM, observation revealed signs continue to be located on wall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-27 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to obtain a physician order for the use of a restraint for one (1) of three (3) residents reviewed for restraints. Resident #25 Findings include: A record review of the facility's policy, Physical Restraint, with a revision date of 10/2016, revealed Restraints shall only be used for the safety and well-being of the residents . Restraints will only be used after other alternatives have been tried unsuccessfully, and only with the informed consent from the resident, physician and/or resident representative . On 7/24/23 at 2:45 PM, Resident # 25 was observed in the day room trying to remove restraint and transfer to a chair. Resident was not able to remove the soft waist restraint, but she managed to get her bottom partially in the chair, while still restrained to the wheelchair. On 7/24/23 at 2:53 PM, when called for assistance, an observation revealed that Licensed Practical Nurse (LPN) #4 released the soft waist restraint from the resident's waist and assisted the resident completely out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to accurately code the discharge Minimum Data Set (MDS) assessment for one (1) of two (2) sampled closed records. Resident #102. Findings include: A record review of the facility's written statement on company letterhead regarding the facility's MDS Policy, revealed The company's MDS policy is to follow the guidelines set forth by the current MDS 3.0 Resident Assessment Instrument (RAI) User's Manual and the Supportive Documentation Requirements User Guide by the Mississippi Division of Medicaid and [NAME] & [NAME], LC. A record review of the admission Record, for Resident #102 revealed the facility admitted the resident on 06/27/2023, with diagnoses that included Aftercare Following Joint Replacement Surgery and End Stage Renal disease. A record review of the Transfer/Discharge Report, for Resident #102, revealed the resident was discharged on 07/05/23, to private home/apartment. with no home health services. A record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to provide the appropriate care and services to a resident who was incontinent to prevent urinary tract infections for one (1) of three (3) residents reviewed for incontinent care. Resident #17. Findings include: A record review of the facility's policy, ADL Care (Activities of Daily Living Care), revised 6/2018, revealed It is policy of this facility to provide appropriate treatment and services in relations to ADL care to residents to ensure all ADL needs are met on a daily basis, while attaining or maintain the resident's highest practicable physical, mental and psychosocial well-being . On 7/24/23 at 12:10 PM, Resident # 17 indicated she has not been changed since her earlier request at 11:30 AM. She stated a Certified Nursing Assistant (CNA) just came in, put supplies in the chair and left the room. There was an odor in the room that smelled of urine covered with fragrance freshener. On 7/24/23 at 3:12 PM, during an interview with Resident #17, she revealed being left in urine and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents and or family were educated on the risk of bedrails and failed to evaluate and document alternatives prior to the application and use of bed rails for one (1) of 22 sampled residents, Resident #75. Findings Include: Review of the facility policy revealed a policy for restraint use but no policy for use of bedrails. On 07/24/23 12:17 PM, observation revealed the resident lying in bed with the head of the bed slightly elevated with quarter side rails up. Observation on 07/25/23 2:02 PM, revealed quarter side rails were up and continued to be raised on the resident's bed. Observation on 07/26/23 at 1:25 PM, revealed quarter side rails continue to be used. Interview on 07/26/23 at 1:30 PM, with the Maintenance Director, revealed bed rails are checked monthly to ensure safety. Review of documentation in the maintenance log system revealed the bed rails were last checked 5/31/23 for proper installation. On 07/26/23 2:13 PM, an interview with the facility Administrator revealed there is no policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure as needed (prn) psychotropic medications were limited to 14 days unless a longer timeframe was documented appropriate by the attending physician for one (1) of 22 residents reviewed. Resident #85 Findings Include: Record review revealed resident is currently taking the following psychotropic med Lexapro 10 mg (milligrams) daily, Seroquel 25 mg @bedtime, Buspirone 15 mg BID (twice a day), Klonopin 0.5mg 1/2 (one-half) daily, and Ativan 0.5mg, 1 tablet by mouth every 12 hours as needed. Review of Order Summary revealed Resident #85 was prescribed Ativan 0.5 mg by mouth every 12 hours as needed for agitation related to anxiety disorder. Prescription start dated noted as 02/23/23. Review of admission Record revealed Resident #85 had an admitting diagnoses of Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety. On 07/24/23 11:30 AM, an observation revealed Resident #85 in dining area during lunch. Resident was yelling out prior to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection for two (2) of twenty-two (22) sampled residents. Resident #17 and #50 Findings include: A record review of the facility's policy, Infection Prevention and Control Program, dated 6/2019, revealed It is a policy of this facility to establish and maintaining infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections . Resident #17 On 07/26/23 at 10:15 AM, during an observation Resident #17 receiving a bed bath, Certified Nurse Aide (CNA) #2 placed two (2) plastic bags at the foot of the bed to use for dirty linen and trash. During the procedure, the CNA knocked the plastic bag containing the soiled brief and wipes off the bed onto the floor two (2) times and both times, she picked the bag up and placed it back onto the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2020-01-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, record review and facility policy review, the facility failed to label opened food items in the cooler, failed to remove expired food items, and failed to remove the scoop out of the sugar container for two (2) out of four (4) kitchen observations. Findings include: A review of the facility's Food Preparation and Receiving policy, not dated, revealed all food items would be appropriately labeled and dated either through manufacturer packaging or staff rotation, and all foods items would be stored in a manner that insured appropriate and timely utilization based on the principles of first in-first out. The policy also revealed safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. On 1/13/2020 at 10:10 AM, an initial tour of the kitchen revealed four (4) clear plastic containers with breakfast cereal without a date or name on the containers, two (2) 16 ounce (oz) beef base containers without a date, half a gallon of cultured whole buttermilk in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-01-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for two (2) of 24 MDS records reviewed, Resident #24 and Resident #1. Findings include: A review of the facility's Minimum Data Set (MDS) Assessment policy, dated May/2006, revealed it is the policy of this facility to follow the Resident Assessment Instrument (RAI) process as set forth by The Centers for Medicare & Medicaid Services (CMS) protocol. The procedure revealed the facility would follow direction per the federal and state guidelines for resident assessment protocol and would refer to the MDS RAI manual. Review the admission Record revealed Resident #24's diagnoses included Unspecified Psychosis not due to a substance or known physiological condition, other Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Other specified Nonpsychotic Mental Disorders, Mild Cognitive Impairment, Unspecified Dementia without Behavioral Disturbance, and Cognitive Communication Deficit. The onset date of the aforementioned diagnoses was 2/19/18.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-01-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and facility policy review, the facility failed to date Resident #37's insulin pen at the time it was opened for one (1) of four (4 ) medication carts observed, Cart 500. Findings include: A review of the facility's Insulin Storage policy, dated May/2010, revealed when insulin was opened the nurse was to date and initial the vial and to check the date prior to each use to assure that it was not expired. An observation, on [DATE] at 9:18 AM, of the 500 Hall Medication (Med) Cart revealed a Tresiba Flextouch 100 unit/milliliter (u/ml) insulin pen which was not dated with an open date for Resident #37. The directions on the pen stated to inject 10 units subcutaneous (sub-q) every day. The pen was opened and labeled for Resident #37. The delivery date on the label was [DATE]. The date open sticker was on the pen without a date. An interview, on [DATE] at 9:20 AM, with Licensed Practical Nurse (LPN) #2 confirmed the insulin pen was open, and she could not tell when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2020-01-16 · tag F0582 — widespreadGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review and facility policy review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) at the time of discharge for Medicare/Centers For Medicare and Medicaid CMS) skilled services for three (3) of three (3) residents reviewed: Resident #105, Resident #311, and Resident #312. Findings include: A review of the facility's statement on letterhead, dated and signed by the Administrator, on 1/16/2020, revealed the facility followed CMS guidance related to the issuing of discharge notification from skilled services. A review of the Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10095 revealed a Medicare health provider must give an advance, completed copy of the NOMNC to enrollees receiving skilled nursing, home health (including psychiatric home health), or comprehensive outpatient rehabilitation facility services, no later than two days before the termination of services. A review of the (Skilled Nursing Facility) SNF Beneficiary Protection Notification Review forms for Residents #105, #311 and #312 revealed: 2. Was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$148,438 in federal fines across 8 penalties. 1 Medicare payment denial on record.
- $35,165 — penalty dated 2026-03-02
- $6,435 — penalty dated 2025-10-29
- $6,500 — penalty dated 2025-10-29
- $12,428 — penalty dated 2025-06-19
- $7,278 — penalty dated 2024-08-01
- $7,279 — penalty dated 2024-08-01
- $10,036 — penalty dated 2024-06-24
- $63,317 — penalty dated 2024-04-03
- Medicare payment denial — starting 2024-05-01 for 21 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| KELLY, CHARLES | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 04/01/2003 |
| KELLY, RITA | Individual | CORPORATE OFFICER | since 04/01/2003 |
| TREND CONSULTANTS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/15/2025 |
| WARNOCK, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/27/2021 |
CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Mississippi Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255103. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.