Comfort Care Nursing Center

Based on interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent an unsupervised exit from the facility, when the resident exited the facility unsupervised and remained outside unattended for approximately two (2) minutes before staff redirected him back into the facility for one (1) of three (3) residents reviewed for supervision. Resident #1 Findings include:A review of the facility's Falls Accidents and Incidents Policy, revised 10/1/25, revealed, Purpose: To promote an environment as free as is possible, of accident hazards over which the facility has control. Scope: Staff to provide adequate supervision and assistive devices to help prevent avoidable accidents and injury.A record review of the facility investigation revealed on 5/8/26 at approximately 8:55 AM, while a visitor was leaving the facility, Resident #1 exited behind the visitor. The investigation revealed Resident #1 was intercepted on the front sidewalk of the facility by the social worker. The investigation included surveillance video that showed 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.

Based on observation, interview and facility policy review the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to foods not dated, foods not labeled, foods not properly sealed, overly ripe produce and unsanitary handling of ready to eat foods for two (2) of two (2) kitchen observations. Findings include: A review of the facility's policy, Food Safety Policy. Reviewed 08/27/2025, revealed, Policy Explanation and Compliance Guidelines.Facility staff shall inspect all food.Labeling, dating, and monitoring.food, including but not limited to leftovers, so it is used by its use-by-date or.discarded; and Keeping foods covered or in tight containers.Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands. On 09/29/2025 at 10:30 AM, during an initial kitchen tour and interview with the Food Service Supervisor (FSS) observed Refrigerator #1 had four (4) trays containing prepared individual salads, individual dished out bowls of pudding, and individual dished out bowls of fruit,…

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.

Based on interview, record review, and facility policy review, the facility failed to review and resolve multiple resident grievances in a timely and effective manner, resulting in ongoing unaddressed environmental concerns expressed during three (3) of 3 consecutive months of Resident Council meetings. Findings include:A review of the Grievance Policy review date 11/17/16 revealed, Purpose To ensure the resident.right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without the fear of discrimination or reprisal . Responsibilities .The facility will review grievances in a timely manner and must make prompt efforts to resolve grievances. The facility will keep the resident appropriately apprised of its progress toward resolution .A record review of the Resident Council Meeting Minutes Reports dated 7/10/25, 8/14/25, and 9/11/25, revealed concerns expressed by the residents during the council meetings for housekeeping concerns regarding floors, trash, and cleaning the rooms in general.Resident #14During 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.

Based on interviews and record reviews, and facility policy review the facility failed to ensure that staff reported allegations of verbal abuse involving two (2) of three (3) residents reviewed for verbal abuse (Resident #66 and #93), and failed to report multiple allegations of misappropriation of resident property (money) involving five (5) of 14 residents in Resident Council (Residents #5, #8, #17, #38, and #81) to the State Agency (SA), as required by federal regulations. Findings include: A record review of the facility's policy titled Abuse, Neglect, and Exploitation Policy, revised 8/26/25, revealed: It is the policy of this facility to provide protection of the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, misappropriation of resident property . Reporting/Response 1. All alleged violations.will be report to the Administrator and/or the Director of Nursing who will report to the appropriate law enforcement officials when applicable, Mississippi State Department of Health…

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.

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 residents were treated with dignity and respect by licensed nursing staff for two (2) of four (4) residents reviewed for resident rights (Resident #66 and #93).Findings Include:A record review of facility policy titled Resident's Rights Policy revealed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.On 9/29/25 at 11:43 AM, Resident #66 reported that night shift Licensed Practical Nurse (LPN)#1 raised her voice during a medication pass and spoke in a demeaning and intimidating tone. The resident stated she felt as though she was talked down to like a child. She also expressed fear of retaliation and concern for other residents who might not be able to speak up.On 9/29/25 at 2:45 PM, Resident #66's roommate, confirmed that LPN#1 was loud and intimidating and said the interaction was uncalled for 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.

Based on interviews and record review, the facility failed to ensure residents' right to be free from verbal abuse by staff for two (2) of three (3) residents reviewed for abuse (Residents #66 and #93).Findings include:A review of facility policy Abuse Neglect and Exploitation Policy with a reviewed date of 8/26/25 revealed Purpose: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, misappropriation of resident property and exploitation.Definitions: 3. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.During an interview on 9/29/25 at 11:43 AM, Resident #66 reported that night shift Licensed Practical Nurse (LPN)#1 raised her voice during a medication pass and spoke in a demeaning and intimidating tone. The resident stated she felt as though she was talked down to like a child. She also expressed fear of retaliation 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.

Based on interviews, record review, and facility policy review, the facility failed to protect residents from misappropriation of resident funds and failed to implement corrective action or reimburse residents after funds were reported missing, affecting five (5) of 14 residents interviewed in Resident Council (Residents #5, #8, #17, #38, and #81).Findings include:A record review of the policy, Abuse Neglect and Exploitation Policy latest review date of 8/26/25 reveals, Purpose: It is the policy of this facility to provide protection of the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, misappropriation of resident property .On 9/30/25 at 10:15 AM, during a Resident Council meeting, Resident #85 (Council President) stated to the State Agency (SA) that multiple residents had reported their money was stolen a few months/weeks ago. She stated she notified the Administrator, who said he was busy, and then reported the issue to the Director of Nursing (DON), who told her all 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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications and biologicals were securely stored to prevent access by unauthorized individuals for one (1) of four (4) days of survey.Findings include:A review of the facility's policy titled Controlled Medication Storage Accountability and Proper Destruction Policy, revised 5/17/18, revealed: .2. The outer lock on the medication cart is locked at all times when not in direct view of the nurse.During an observation on 9/29/25 at 11:23 AM, the wound care cart located on the 200 Hall was noted to be unlocked and unattended, with wound cleanser left unsecured on top of the cart. The cart remained unlocked for fifteen (15) minutes, until 11:38 AM when Registered Nurse (RN)#1 arrived, placed the unsecured cleanser inside the cart, and then locked it.During an interview with RN #1 on 9/29/25 at 3:51 PM, she stated the cart should always be locked but explained that the keypad locking mechanism had been malfunctioning, requiring her to use a manual key. She acknowledged that 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.

Based on interview, record review, and facility policy review, the facility failed to notify the physician and the resident's representative of the initiation of psychosocial services for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to ensure that the physician and resident representative (RR) were informed when 1:1 psychosocial therapy services were initiated by a third-party provider. Findings Included: A review of the facility's Resident Rights Notification of Changes Policy, reviewed date 05/30/2025 revealed, It is the policy of (Proper Name of Facility) to notify the resident; consult with the physician; and notify, consistent with his or her authority, the resident representative of changes as discussed in the policy . On 6/11/25 at 11:00 AM, a phone interview with the complainant revealed that there is a Licensed Certified Social Worker (LCSW) that is not employed by the nursing home facility (3rd Party Provider)…

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.

Based on record review, interview, and facility policy review, the facility failed to develop a comprehensive care plan that included all services provided to address the psychosocial needs of three (3) of three (3) sampled residents receiving individual psychosocial therapy (Residents #4, #5, and #6), with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to include ongoing psychosocial therapy services provided by the Licensed Clinical Social Worker (LCSW) in the residents care plans to ensure coordination of care, consistent monitoring, and individualized interventions based on the residents' psychosocial needs. Findings included: A review of the facility's Comprehensive Person-Centered Care Plan Policy, reviewed on 1/24/2024, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered plan of care for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are…

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.

Based on record review, interview, and facility policy review, the facility failed to ensure services were provided and documented according to professional standards for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to obtain a physician's order for ongoing psychosocial therapy services provided by a third party Licensed Clinical Social Worker (LCSW), resulting in services being delivered without appropriate physician oversight. Findings included: A review of the facility policy titled, Physician Orders, reviewed 01/24/2024, revealed, .Scope: Physician's orders that will be obtained, noted, and implemented appropriately . During a phone interview on 6/11/25 at 11:00 AM, the complainant revealed that there are no Physician's Orders for residents who are seen at the facility by a LCSW for behavioral therapy. She explained the LCSW is not employed by the nursing home facility (3rd Party Provider) and she refuses to share 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.

Based on record review, interview, and facility policy review, the facility failed to identify, assess, and coordinate behavioral health services for three (3) of three (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving these services. Specifically, the facility allowed a Licensed Certified Social Worker (LCSW) to provide ongoing cognitive behavioral therapy within the facility without physician oversight, formal referral, or interdisciplinary coordination in which she accepted self-referred residents, regardless of whether clinical need had been identified. Findings Included: A review of the facility's policy, Dementia and Behavioral Health Services, reviewed 02/28/2024, revealed, .It is the policy of this facility that all residents receive the appropriate treatment and services for .necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning .Discussion .6. Specialized services and supports will vary…

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.

Based on interview, record review, and facility policy review, the facility failed to ensure complete and readily accessible medical records were maintained for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the therapist maintained resident therapy documentation separately from the facility's medical record and did not share or integrate the documentation into the residents' facility medical records. Findings included: A review of the facility's policy titled, Medical And Personal Resident Records, reviewed 01/24/2024, revealed, .It is the policy .that the resident's personal and medical records shall be maintained in accordance with professional standards and practice Discussion: 1. The medical record shall be completely and accurately documented, readily accessible .to facilitate retrieval and compiling of information . On 6/11/2025 at 11:00 AM, during a phone interview with the complainant, she stated that a Licensed Clinical Social Worker…

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.

Based on staff interview and record review, the facility failed to electronically submit accurate direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for one (1) of three (3) months reviewed. December 2023 Findings include: A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility had triggered for Four or More Days Within the Quarter with no RN (Registered Nurse) Hours and Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage from 12/2/23 to 12/31/23. Record review of facility policy Nurse Staffing Information, revised 11/14/23, revealed it did not address the accurate submission of PBJ data. On 5/13/24 at 12:48 PM, the Business Office Coordinator stated she was unaware the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY (Fiscal Year) 2024. She explained she was responsible for entering the PBJ data for the facility and kept 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.