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Riverview Nursing & Rehabilitation Center

1600 West Claiborne Avenue Extended, Greenwood, MS 38930 · Non profit - Corporation · 91 certified beds · (662) 453-8140 Medicare & Medicaid certified

Call the home — (662) 453-8140 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Nov 2024Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • 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
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
408 W Market St · (662) 453-0722 · Call to confirm hours
Pharmacy
513 Highway 82 W · (662) 374-0904 · Call to confirm hours
Grocery
1000 Broad St · (662) 453-6095 · Call to confirm hours
Park
Broad St @ M · Typically dawn to dusk

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 3 of 5
Short-stay residentsrehab / post-hospital 2 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 fell from 2 to 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.2%20.5%15.4%worse
Long-stay residents who lose too much weight2.0%6.2%5.4%better
Long-stay residents with a catheter left in their bladder1.1%1.4%0.9%worse
Long-stay residents with a urinary tract infection3.7%2.5%2.0%worse
Long-stay residents with depressive symptoms1.3%1.6%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury0.4%3.1%3.3%better
Long-stay residents whose ability to walk worsened34.9%19.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.6%23.8%18.9%worse
Long-stay residents given the seasonal flu vaccine95.2%97.0%95.3%typical
Long-stay residents with pressure ulcers5.9%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control25.6%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.3%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.5%1.4%better
Short-stay residents given the seasonal flu vaccine59.3%84.6%79.4%worse
Short-stay residents rehospitalized after admission19.3%27.7%22.6%better
Short-stay residents with an outpatient ER visit21.0%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.252.431.67better
Long-stay outpatient ER visits per 1,000 resident days2.942.861.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ 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.

49.3% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.3%U.S. median 51.5%
Got home and stayed home
12.1%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.3%CMS range 34.7–64.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.1%CMS range 7.5–19.310.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened14.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 2022–Sep 2024CMS 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

1.25
RN hours/ resident / day
0.44
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.91
Total nurse hours/ resident / day
0.84
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 91 beds and averages 73.2 residents a day — about 80% occupied, or roughly 18 beds typically open. It usually has some room. 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.25 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below 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 3.15 hrs/resident/day on weekends vs 4.22 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 1.42 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

15
deficiencies at the latest standard inspection (2024-11-06)
1
at the previous standard inspection (2023-03-16)

Deficiencies are more than at the previous inspection — worsening. 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.

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.

ABCDEFGHIJKL

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Ecited before2024-11-06 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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, resident and staff interview, record review and facility policy review, the facility failed to develop and/or implement a person-centered care plan for monitoring side effects of medications, range of motion (ROM) and providing nail care for 11 of 24 resident care plans reviewed. Resident #4, #9, #10, #17, #18, #19, #39, #44, #51, #55 and #58. Findings Include: Record review of the facility policy titled Comprehensive Assessments and the Care Delivery Process with a revision date of 12/16 revealed under, Policy Statement: Comprehensive assessments will be conducted to assist in developing person-centered care plans. Resident # 4 Record review of Resident #4's care plan revealed under focus, Closed fracture of right tibia and fibula, date initiated 05/01/2024. Interventions included Xarelto 10 milligram tablet, monitor for side effects such as abdominal pain, back pain, itching, dizziness, muscle spasms, trouble sleeping, and anxiety. Date initiated 5/6/2024. In an interview on 11/05/24 at…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-06 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement 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 staff interview, record review, and facility policy review the facility failed to monitor for side effects and obtain a stop date for a psychotropic medication for five (5) of 40 residents receiving psychotropic medications reviewed. Resident #10, #18, #44, #51 and #55 Findings include: A review of the policy titled, Behavioral Assessment, Intervention and Monitoring, revised December 2016 revealed . Management: 10.) When medications are prescribed for behavioral symptoms, documentation will include a.) Rationale for use . h.) Monitoring for efficacy and adverse consequences . Resident #10 Record review of Resident #10's Order Summary Report with active orders as of 11/3/24 revealed an order dated 10/18/24 Buspirone HCI oral tablet 10 mg (milligrams) Give 2 tablets by mouth two times a day related to anxiety disorder. An additional order dated 10/7/24 revealed Venlafaxine HCI oral tablet 75 mg Give 1 tablet by mouth two times a day related to anxiety disorder. The order summary revealed there was not an order to monitor for side effects of the multiple psychotropic…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews and record reviews the facility failed to promote dignity as evidenced by a resident not being assisted with his meal immediately after nursing staff delivered the meal tray to his room for one (1) of eight (8) residents reviewed for dining. Resident #16 Findings Included: Record review of the facility policy titled, Residents' Rights with no revision date revealed Residents Rights Under Federal Law. The facility shall protect and promote the rights of each resident, including each of the following rights: 1. The resident has a right to a dignified existence, self-determination, communication with access to people and services inside and outside the facility . On 11/3/24 at 5:28 PM, during a continuous observation, Resident #16 was observed in bed as Certified Nursing Assistant (CNA) #8 delivered a meal tray to his room, placing it on the overbed table positioned against the wall and out of the resident's reach. The tray remained covered as CNA #8 exited the room without assisting Resident #16. She then delivered the meal tray to 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interview, record review, and facility policy review, the facility failed to honor a resident's right to make health care decisions for one (1) of 25 residents reviewed for advanced directives. Resident #58 Findings Include: Record review of the facility policy titled Advanced Directives with a revision date of 8/11 revealed under, Policy Interpretation and Implementation: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. Record review of the Advanced Directive Form for Resident #58 revealed a family member signed the form dated 4/23/24, with no signature from the resident. An interview with Resident #58 on 11/4/24 at 1:20 PM, revealed when he admitted to the facility, he did not sign his advanced directives form and explained that no one had spoken to him regarding his code…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide a safe, clean, and comfortable environment, as evidenced by an over-bed table with exposed jagged edging (Resident #4) and a sagging mattress (Resident #58) for two (2) of 61 residents. Findings include: Review of the facility policy titled Maintenance Service with a revision date of December 2009 revealed, Maintenance service shall be provided to all areas of the building, grounds, and equipment. J. Ensuring equipment is maintained in good, operational working order. Resident #4 An observation on 11/03/24 at 4:25 PM, revealed Resident #4 lying in bed with her overbed table pulled up to her. The overbed table edging was missing around the table, exposing chipped and jagged wood. An observation on 11/04/24 at 8:25 AM, revealed the overbed table remained in the same condition as the prior day. During an interview and observation on 11/04/24 at 1:30 PM, Certified Nurse Aide (CNA) #4 confirmed that Resident #4's overbed table was tattered and torn and revealed she had not…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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, staff interview, record review and facility policy review, the facility failed to ensure residents were free from physical restraints as evidenced by a resident with full side rails to both sides of the resident's bed for one (1) of two (2) residents reviewed for restraints. Resident #44. Findings Include: A review of the facility policy titled Residents' Rights with no revision date revealed The facility shall protect and promote the rights of each resident, including each of the following rights: . The resident has a right to be free from any physical restraints imposed or psychoactive drugs administered for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. During an observation on 11/03/24 at 3:35 PM, Resident #44 was observed in bed with side rails extending the length of the bed on both sides. In an interview on 1/4/24 at 1:12 PM, Certified Nursing Assistant (CNA) #3 stated that she did not know why Resident #44 had full side rails on his bed. During an interview on 1/4/24 at 1:17 PM, with a Licensed…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0641 — isolated
    Ensure 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 ensure that the Minimum Data Set Assessment (MDS) was coded accurately for one (1) of 22 sampled residents. Resident #19. Findings Included: Record review of the facility policy, titled Resident assessment Instrument revealed Policy Statement: A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. Policy Interpretation and Implementation .4. Information derived from comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 7. All persons who have completed any portion of the MDS Resident Assessment Form must sign such a document attesting to the accuracy of such information. Record review of Resident #19's Annual MDS with Assessment Reference Date (ARD) of 7/2/24, revealed in Section A 1500 coded as No, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, record review, and facility policy review the facility failed to complete a baseline care plan timely and provide a summary of the baseline care plan to the resident and their representative for two (2) of three (3) baseline care plans reviewed. Resident 59 and 166 Findings include: A review of the facility policy titled, Care Plans-Baseline, with a revision date of 12/2016 revealed Policy Interpretation and Implementation: 1.) To ensure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 4.) The residents and their representatives will be provided with a summary of the baseline care plan . Resident #59 A record review of the Baseline Care Plan for Resident #59 revealed the care plan was completed on 8/22/24 with no signature of the resident or representative acknowledgement of receipt of the care plan summary findings. In an interview with Resident # 59 on 11/4/24 at 3:00 PM, she revealed that there were no staff that discussed her…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, resident and staff interviews and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) care to maintain hygiene as evidenced by: Resident # 9, # 17, #58 were observed with long jagged fingernails and Resident #12 was observed with unkept and greasy hair and an unkept beard for four (4) of 61 residents reviewed for ADL care. Residents #9, #12, #17 and #58. Findings Included: Record review of a statement on facility letterhead, undated, and signed by the Administrator revealed We do not have a direct policy ADLs. Resident #9 An observation on 11/03/24 at 2:30 PM revealed, Resident #9 lying in bed with long jagged nails on both hands, measuring approximately three-eighths (3/8) inch in length past the tips of the fingers with a brown substance underneath. An observation and interview with the Director of Nursing (DON) on 11/4/24 at 1:10 PM, confirmed Resident #9's nails were long and had a brown substance underneath. She revealed the treatment nurse…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 provide the services needed for a resident to maintain and/or improve their level of range of motion (ROM) and mobility for four (4) of 32 residents reviewed for positioning and mobility. (Resident #17, # 19, #22, and #39). Findings include: Record review of facility policy titled Resident Mobility and Range of Motion with a revision date of 7/2017 revealed Policy Statement, 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited will receive appropriate services, equipment and assistance to maintain or improve mobility unless a reduction in mobility is unavoidable. Resident #17 An observation on 11/03/24 at 2:44 PM revealed Resident #17 to have a right and left-hand contracture with no device in place. In an observation of Resident #17 with Licensed Practical Nurse (LPN) #1 on 11/04/24 at 12:50 PM,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2024-11-06 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and facility policy review, the facility failed to ensure sufficient weekend nursing staffing for the 3rd quarter payroll-based journal (PBJ) for one (1) of three (3) quarters reviewed. Findings include: Record review of the facility policy titled Staffing with a revised date of April 2007 revealed, . 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 3 2024 (April 1-June 30), revealed Excessively Low Weekend Staffing-Triggered. Triggered=Submitted Weekend Staffing data is excessively low. An interview on 11/04/24 at 10:00 AM, the Assistant Director of Nurses (ADON) revealed she is responsible for staff development and scheduling. She revealed she was not employed as the ADON during the 3rd quarter dates of April-June 2024 but worked part-time for the facility. She revealed that the facility had an issue maintaining enough staff for the weekends during that time and confirmed that after she…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record reviews and facility policy review, the facility failed to monitor a resident receiving anticoagulant medication for side effects for one (1) of (10) residents on anticoagulant medications. Resident #4 Findings include: Record review of the facility policy titled Anticoagulation-Clinical Protocol with a revision date of September 2012 revealed . Monitoring and Follow-Up . 4. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in the urine), hemoptysis (vomiting blood), or other evidence of bleeding, the nurse will discuss the situation with the physician . Record review of the Order Summary Report with active orders as of 11/5/24 revealed an order with a start date of 6/10/24 for Xarelto Oral Tablet 10 mg (Rivaroxaban) Give 1 tablet by mouth one time a day. Record review of the Order Summary Report and the Medication Administration Record (MAR) for November 2024…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, and facility policy review, the facility failed to accommodate a resident's food preference during one (1) of three (3) meal services observed. (Resident # 55) Findings Include: A review of the facility policy titled, Resident Nutrition Services, with a revision date of 11/2015 revealed, Policy Statement: Each resident shall receive meals, with preferences accommodated . A dining observation on 11/3/24 at 5:45 PM, revealed the admission Nurse set the meal tray up for Resident #55. The meal tray was observed to have a ham and cheese sandwich with no observation of the admission Nurse offering the resident condiments for the sandwich, and there were no condiments observed on the meal tray. An interview with the admission Nurse on 11/3/24 at 5:48 PM, confirmed Resident # 55 did not have any condiments on her meal tray and that the residents were provided with condiments if they asked for them. In an interview with Resident #55 on 11/3/24 at 5:50 PM, she revealed she prefers both mayonnaise and mustard on her sandwiches. A continued…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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, resident/staff interviews, and facility policy review, the facility failed to ensure snacks/nourishments were offered to residents for two (2) of four (4) survey days. Resident #10. Findings include: Review of the facility policy, Resident Nutrition Services, with a revised date of November 2015, revealed, . Policy Interpretation and Implementation .8 . Snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns . During an interview on 11/03/24 at 03:45 PM, Resident #10 revealed that she often gets hungry, especially at bedtime. She revealed they put the snacks out at the nurse's station, but you must go up there if you want anything. They don't come around to your room and offer any snacks. She revealed that one night, I specifically asked my Certified Nursing Assistant (CNA) for cheese and crackers, but she didn't get anything for me. She may have forgotten…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, record review, staff interview and facility policy review the facility failed to prevent the possibility of the spread of infection during wound care for one (1) of two (2) treatments observed. Resident # 11. Findings Included: Record review of facility policy titled, Enhanced Barrier Precautions Checklist revised January 2012 revealed .Policy Interpretation and Implementation 1. Staff shall apply Enhanced Barrier Precautions to the care of all residents in high contact care activities regardless of suspected or confirmed presence of infectious disease . Record review of facility policy titled Pressure Ulcer Treatment revised September 2013, revealed . Steps in the Procedure 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field .7. Put on clean gloves. Loosen tape and remove soiled dressing. 8. Pull glove over dressing and discard into plastic or biohazard bag. 9. Wash and dry your hands thoroughly .14. Put on clean gloves 16. Cleanse the wound with the ordered cleanser. Use a syringe to irrigate the wound, if ordered.…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 staff interviews, facility policy/procedure review, and record review, the facility failed to implement the interventions of a care plan for a resident related to medication administration for one (1) of six (6) residents care plans reviewed. Resident #1 Findings include: Review of the facility's policy/procedure Using the Care Plan last revised August 2006 revealed the Policy Statement: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Record review of Resident #1's care plan revealed, Pain risk r/t (related to) diagnosis Breast Cancer and impaired mobility .Start date 10/06/2023 .Roxicodone 30 mg (milligrams) tablet: take one tablet by mouth Q (every) 4 (four) hours 12A/4A .Dilaudid 4 mg tablet: take three tables (12 mg) by mouth q 4 hours PRN (as needed) . Record review of Resident #1's Physician Orders List revealed orders dated 10/6/23 for Roxicodone 30 MG…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, facility policy/procedure review, and record review, the facility failed to ensure that one (1) of six (6) residents sampled received care and services that would meet the professional standards of quality as evidenced by Resident #1 not receiving medications as ordered. Findings include: Review of the facility's policy for Administering Medications last revised December 2012 revealed Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Review of the facility's policy for Adverse Consequences and Medication Errors last revised April 2014 revealed the .Policy Interpretation and Implementation . 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medication errors include: c. Wrong dose . Record review…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 staff and resident interviews, facility policy/procedure review, and record review the facility failed to ensure that one (1) of six (6) residents sampled were free from any significant medication errors. Resident #1. Findings include: Review of the facility's policy for Administering Medications last revised December 2012 revealed Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed . Record review of the facility's policy for Adverse Consequences and Medication Errors last revised April 2014 revealed, .Policy Interpretation and Implementation .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medication errors include: .c. Wrong dose . Record review of the facility's Charge Nurse-LPN(Licensed Practical Nurse) job description…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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, facility policy review and record review, the facility failed to label an enteral feeding with nurse's initials, and date and time the formula was hung/administered for one (1) of five (5) residents with enteral feeding. Resident #17 Findings include: A record review of the facility policy titled, Enteral Tube Feeding via Continuous Pump with a revision date of March 2015, revealed, . Initiate Feeding . 5. On the formula label, document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . An observation on 03/13/23 at 10:20 AM, revealed Resident #17's enteral feeding of Jevity 1.2 was infusing. There was no date, time initiated, or nurse initials noted on the bottle. An observation on 03/13/23 at 01:34 PM, revealed Resident #17's enteral feeding of Jevity 1.2 was infusing. The Jevity 1.2 bottle had no date, time initiated or nurse initials on the bottle. An interview on 03/13/23 at 02:05 PM, the Director of…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-01-15 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 ensure a medication error rate of less than five percent (5%), out of 27 medication administrations observed. The medication error rate was 14.81%. Findings include: Review of the facility's policy titled, Administering Medications through an Enteral Tube, revised March 2015, revealed, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Steps in the Procedure: 21. When correct tube placement and acceptable GRV have been verified, flush tubing with 15-30 ml warm sterile water (or prescribed amount). 23. Dilute the crushed or split medication with 15-30 ml room temperature purified water (or prescribed amount). 26. If administering more than one medication, flush with 5 ml (or prescribed amount) room temperature purified water between medications. 27. When the last of the medication begins to drain from the tubing, flush the tubing with 5 ml of room temperature purified water (or prescribed amount). An…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-01-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure measures to prevent the possible spread of infection and/or cross contamination for five (5) of nine (9) residents observed during the medication administration observations, Residents #2, #13, #15, #29, and #52. Findings include: Review of the facility's Infection Prevention and Control Program policy, revised October 2018, revealed the Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation: The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. The program is based on national infection prevention and control standards. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and facility policy review, the facility failed to provide privacy for Resident #2 during the administration of medications through a Percutaneous Endoscopic Gastrostomy (PEG) Tube, for one (1) of nine (9) residents observed for medication administration. Findings include: Record review of the facility's Quality of Life - Dignity policy, revised August 2009, revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation: 1. Residents shall be treated with dignity and respect at all times; 2. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. On 1/12/2020, at 3:17 PM, during an observation of Percutaneous Endoscopic Gastrostomy (PEG) tube medication administration, Licensed Practical…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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, staff and resident interviews, record review and facility policy review, the facility failed to develop a care plan to address Resident #27's hospital return with a new medication and diagnosis; to implement Resident #45's care plan for Passive Range of Motion (PROM) exercises, to implement Resident #40's use of an alarm only while in bed, and to store and change Residents #24 and #50's oxygen (O2) tubing. This concern was identified for five (5) of 19 residents reviewed. Findings include: Review of the facility's Care Plan - Comprehensive policy, dated September 2010, revealed: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, resident interview, facility policy review and record review, the facility failed to provide Resident #45's Passive Range of Motion (PROM) exercises correctly to prevent the potential decline in range of motion for one of three (1 of 3) residents reviewed receiving restorative services. Findings include: Review of the facility's policy titled, Restorative Nursing Services, revised July 2017, revealed, Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. On 1/12/19, at 3:40 PM, during an interview with Resident #45, he stated he was supposed to have Restorative Nursing for exercises to his shoulders but they don't do it. Record review of the January 2020 Physician's Orders revealed an order, dated 11/14/19, to admit Resident #45 to the Restorative Nursing Program for 1) Active Range of Motion (AROM) right shoulder flexion exercises four (4) sets 15 repetitions (reps) 2) Passive Range of Motion (PROM) left (L) Shoulder Flexion/Abduction 4 sets 15 second holds six (6) days weekly. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, staff interview, and record review, the facility failed to address Resident #40's care plan after a fall with an intervention to prevent the potential for another fall. Resident #40 was assessed a high risk for falls by the facility, on 11/15/2019, and experienced another fall on 12/9/2019. This concern was identified for one (1) of two (2) residents reviewed for falls. Findings include: Review of Resident #40's Resident Incident Report, dated 12/09/2019 at 2:30 PM, revealed Resident #40 had a fall, in which she entered another resident's room, threw the covers back on the bed and attempted to crawl in bed. She was found laying on the floor next to the bed with her knees bent and asking for a pillow so she could put it under her head. Review of Resident #40's care plan, with the reviewed/update of 11/20/19, revealed the Problem/Need for risk for fall related to (r/t) a history (HX) of falls, and impaired mobility. The Approaches included: call light within reach, bed in lowest position and wheels are locked, non-skid footwear, fall assessment quarterly and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 observation, staff interview, resident interview, record review and facility policy review, the facility failed to store and change oxygen (O2) tubing to prevent the possibility of infection/cross contamination, for two (2) of 17 residents reviewed on oxygen therapy. Resident #50 and Resident #24 Findings include: Review of the facility's policy titled, Changing of Oxygen Supplies, dated September 2019, revealed: Policy Statement: Riverview Nursing and Rehabilitation Center incorporates procedures to maintain an environment as free of infection as possible for our residents. Policy Interpretation and Implementation: 1. Designated nursing staff will change oxygen tubing, mask, and cannulas at least every (7) days and PRN (as needed), 2. Designated nursing staff will label oxygen tubing, cannulas and oxygen humidifier water containers with date of change in a visible site. 3. Designated nursing staff will place opened oxygen tubing, mask and cannulas in labeled/dated container/covering while not in use. An observation, on 1/12/2020 at 5:01 PM, in Resident #24's room,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 observation, staff interview and facility policy review, the facility failed to properly label medications for two of four (2 of 4) medication carts and one (1) of two (2) medication storage rooms. Findings include: Review of the facility's policy titled, Labeling of Medication Containers, revised April 2007, revealed the Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Under a section titled Policy Interpretation and Implementation it stated: 2. Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number (if applicable); f. The date that the medication was dispensed; g. Appropriate accessory and cautionary statements; h.…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
DASPIT, RICHARDIndividualCORPORATE DIRECTORsince 12/01/1995
JOYCE, KIMBERLYIndividualCORPORATE OFFICERsince 08/02/2021
PEELER, LONNIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2014
GUISE, RAQUELIndividualADP OF THE SNFsince 05/20/2025
WARRINGTON, JAMESIndividualADP OF THE SNFsince 05/20/2025

CMS files one row per role, so the 7 rows in the source record cover these 5 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.

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.

$5.6M
Net patient revenuemost recent cost report
-9.6%
Operating marginrevenue minus expenses
$471K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 88%Medicare 6%Other / private 7%

About 88% 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 $471K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$324per resident / day
operating cost
$9,841per month
≈ monthly operating cost
$295per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Mississippi
$9,581/mo
Nursing home (semi-private)
$9,885/mo
Nursing home (private)
$4,369/mo
Assisted living

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 255216. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-06, 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.

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