Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cornerstone Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Unsanitary food storage and dietary conditions were observed in the kitchen area. Food debris, spilled liquids, discarded silverware, paper, condiment packs, and food items were found on the floor, and grease and food buildup were seen on the steam table backsplash. A bag of breadsticks was over a month old, Freezer 2 was at 48 degrees F with thawed food inside, a clean dish rack had dirty gloves and food debris on it, and a dietary employee handled dinner rolls with soiled gloves during tray line assembly.
The facility failed to submit accurate PBJ staffing data for one quarter reviewed. The Administrator and PBJ Coordinator confirmed that DON, RN, and LPN administrative hours were included in PBJ even when those staff did not provide direct resident care, and the CASPER report triggered for excessively low weekend staffing.
Improper labeling of opened multi-dose medication vials was found on two medication carts. An LPN and the ADON identified that several opened multi-dose vials, including insulin and ophthalmic solutions, were missing open dates or had dates that did not align with the facility policy for dating and discarding after opening. Residents affected had active orders for the medications observed, including eye drops and insulin.
Failure to provide required Medicare coverage notices. The facility did not ensure a resident or the resident’s representative received the SNF ABN, and staff stated they believed the NOMNC was the only notice needed. The facility also had no policy specific to Beneficiary Notices, including ABNs. The resident had been admitted with HF.
A resident receiving dialysis three times weekly was not coded for dialysis in Section O on two quarterly MDS assessments. The MDS Nurse confirmed the resident attended all scheduled dialysis treatments but did not code them because dialysis center communication sheets were unavailable during the look-back period. The resident had ESRD and dependence on renal dialysis, and the ADM stated the MDS should accurately reflect dialysis services.
Failure to develop and implement comprehensive person-centered care plans for three residents. One resident with Alzheimer's disease and severe cognitive impairment had unwashed, matted hair and a foul odor, and staff confirmed he needed hands-on bathing and shampoo assistance but was coded as independent. Another resident with dementia and weakness had unclean, matted hair with scalp buildup despite a bathing/showering intervention in the care plan. A third resident who used tobacco had no smoking care plan, and the MDS Nurse confirmed the omission.
Failure to Provide Hair Care and Shampooing Assistance: Two residents who depended on staff for ADL care were observed with unclean, matted, and tangled hair, and one had a foul odor. Staff and the Administrator confirmed the hair had not been washed, despite facility policy and routine bathing expectations. Both residents had severe cognitive impairment and diagnoses including dementia-related conditions.
Improper perineal care was observed for a resident during CNA care when the aide cleansed the front perineal area, then after the resident had a BM, re-dipped previously used washcloths into the same water basin and used that water to cleanse the back perineal area. The CNA said she reused the washcloths because she was out of clean supplies and acknowledged the practice was incorrect; the DON confirmed additional clean washcloths should have been obtained. The resident had epilepsy, needed assistance with personal care, had moderate cognitive impairment, and was always incontinent of bowel and bladder.
Several residents and their representatives reported that certain CNAs consistently displayed rude and unfriendly behavior, including abrupt communication and lack of assistance with personal care tasks. Staff interviews and disciplinary records confirmed ongoing issues with unprofessional conduct, such as loud and disrespectful interactions with residents and their families. Facility leadership was aware of these concerns, but the behavior persisted, resulting in a deficiency related to resident dignity and respect.
The facility inaccurately submitted the Payroll-Based Journal (PBJ) for the 4th quarter of FY 2024, triggering low weekend staffing. The facility's policy requires electronic reporting of staffing data to CMS, including agency and contract staff hours. The DON and Administrator confirmed that some agency staff hours were not accurately submitted, resulting in the low staffing trigger.
The facility failed to provide adequate personal hygiene care for five residents, as observed and confirmed through interviews and record reviews. A resident was found with facial hair that had not been addressed since her admission, despite her preference for hair removal. Both a CNA and an RN Supervisor acknowledged that facial hair should be managed during bath or shower times. Another resident had long, jagged fingernails that had not been trimmed since his admission, which he expressed a desire to have cut. The CNA and RN Supervisor confirmed the need for regular nail care to prevent potential injuries and infections.
A facility failed to obtain a Level II PASARR status change for a resident after an inpatient psychiatric hospital stay. The resident, with diagnoses including Parkinsonism and Bipolar II Disorder, was discharged to a psychiatric facility. The former Social Services Director did not submit the required change of status form, mistakenly believing a negative Level I PAS exempted further action. The Administrator confirmed the oversight, which led to the deficiency.
A resident with Huntington's Disease was found lying on a deflated air mattress, which was supposed to be a low air loss mattress for pressure redistribution. Despite staff presence, the deflated mattress was not reported or addressed promptly. A CNA noticed the issue but did not report it, and an LPN confirmed the mattress was deflated. The Maintenance Director later turned on the control box, inflating the mattress. The DON acknowledged the potential for worsening conditions due to the deflated mattress.
A resident was left with ten pills unattended on their over bed table by an LPN, contrary to facility policy requiring observation during medication administration. The RN Supervisor and DON confirmed the policy breach, highlighting the risk of medication errors or unauthorized access. The resident, cognitively intact, had diagnoses including Major Depressive Disorder and Anxiety Disorder.
The facility failed to implement ADL care plans for five residents with cognitive impairments and physical limitations, resulting in unmet personal hygiene needs. Observations revealed residents with unshaved facial hair and long, jagged fingernails, despite care plans specifying assistance with these tasks. Staff confirmed the care plans were not followed, highlighting a deficiency in meeting residents' personal hygiene needs.
The facility failed to maintain clean wheelchairs for three residents, as observed by surveyors. Interviews revealed that night shift CNAs were responsible for cleaning, but there was no documentation to confirm completion. The wheelchairs were found with a thick gray substance and one had cracked wheels. The residents had medical conditions such as respiratory failure and cerebrovascular disease.
A facility failed to document and address grievances from a resident and their family, despite multiple complaints about care issues such as the resident being left wet or dirty. The facility's grievance log showed no entries for the resident, and interviews with staff confirmed frequent complaints. The administrator and DON were aware of the issues but did not complete formal grievance documentation or ensure proper follow-up.
The facility failed to follow a comprehensive care plan for a resident who was incontinent of bladder. The resident was not checked every two hours as required, resulting in the resident being found with a soaked incontinent brief. Staff interviews confirmed the care plan was not followed.
A resident with multiple diagnoses, including a Stage 3 Pressure Ulcer, was left in a wet brief for over four hours because the CNA did not check on him as required. The ADON and DON confirmed that CNAs must check incontinent residents every two hours, even if they are asleep.
Unsanitary Food Storage and Dietary Department Conditions
Penalty
Summary
The facility failed to store and serve food in a sanitary manner and failed to maintain a clean dietary department. Facility policy stated that all food preparation areas, food services, and dining areas were to be maintained in a clean and sanitary condition, and that the Dining Services Director was responsible for ensuring the kitchen was maintained in a clean and sanitary manner. During observation, a large amount of food debris and spilled liquids were seen throughout the dietary department, along with discarded silverware, paper, butter packs, jelly packs, dried pasta, shredded cheese, and lettuce on the floor. The floor was described as extremely sticky and the area as very unkept, and there was also a large amount of grease and food buildup on the glass of the steam table backsplash. Additional observations showed a gallon-size plastic bag dated 02/24/26 containing about 20 breadsticks on a cart beside a blender, and the Dietary Manager confirmed the breadsticks should have been discarded and were over a month old. Freezer 2 was observed at 48 degrees F with thawed biscuits, rolls, and breaded chicken strips inside that were mushy to the touch and not frozen; the Dietary Manager stated a freezer had broken down about a week earlier and the items had been moved to this freezer, but she thought it was working. A clean dish rack in the dish room had dirty gloves on it with clean dishes, discarded salt and pepper packets, and food debris on the bottom rack. During tray line assembly, a dietary employee with soiled gloves touched dinner rolls while assembling lunch trays, and the Dietary Manager confirmed dietary employees should not touch food with dirty gloves.
Inaccurate PBJ Staffing Reporting
Penalty
Summary
The facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one quarter reviewed, specifically the 4th Quarter 2025 (July 1-September 30). Review of the facility policy on reporting direct-care staffing information showed that staffing and census information are to be reported electronically to CMS through the PBJ system in compliance with Section 6106 of the Affordable Care Act. Review of the PBJ Staffing Data Report CASPER Report 1705D for FY Quarter 4 2025 showed the facility triggered for excessively low weekend staffing. During interview, the Administrator and PBJ Coordinator confirmed the facility included DON hours, RN administrative hours, and LPN administrative hours in PBJ reporting even when those staff did not provide direct resident care. The Administrator stated that entering those hours incorrectly increased the number of staff shown during the week and caused staffing numbers to fall on the weekends.
Improper labeling of opened multi-dose medication vials
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored in accordance with accepted standards of practice for two of three medication carts observed. During observation of the A-Hall medication cart, several opened multi-dose vials were found with missing or outdated open dates, including Olopatadine HCl ophthalmic solution, Latanoprost ophthalmic solution, Lantus subcutaneous solution, Artificial Tears ophthalmic solution, and Timolol maleate solution. The facility policy reviewed stated that multi-dose vials that have been opened or accessed are to be dated and discarded within 28 days, and the LPN observing the cart stated that insulin and other multi-dose vials were good for 30 days after opening. During observation of the B-Hall medication cart, an opened multi-dose vial of Latanoprost ophthalmic solution for another resident was also found without an open date. The ADON confirmed that all multi-dose vials should have an open date and stated insulin is only good for 28 days after opening, while other multi-dose medications such as eye drops are typically good for 30 days after opening. The residents involved included individuals with diagnoses such as heart failure, Alzheimer's disease, type 2 diabetes mellitus, protein-calorie malnutrition, Huntington's disease, and traumatic subdural hemorrhage, and active orders were present for the medications observed.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure that residents or their representatives were provided with required Beneficiary Notices, including Skilled Nursing Facility Advanced Beneficiary Notices (ABNs), for one of three residents reviewed for Beneficiary Protection Notifications. Review of a statement on facility letterhead dated 4/7/26 and signed by the Administrator showed the facility did not have a policy specific to Beneficiary Notices, including ABNs. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review form showed that one resident remained in the facility, but Resident #4 was not provided with a Skilled Nursing Facility ABN. During interview, the Business Office Manager stated she did not provide the SNF ABN to the resident or responsible party and believed the Notice of Medicare Non-Coverage (NOMNC) was enough to cover all required notice. The Administrator confirmed the same understanding and believed the NOMNC was the only notice required. The admission record showed Resident #4 was admitted on 12/19/2025 with a diagnosis of Heart Failure.
MDS Dialysis Coding Not Accurately Completed
Penalty
Summary
The facility failed to accurately complete Section O of the MDS quarterly assessment for one resident who received dialysis three times a week. Record review showed the resident had an order for dialysis on Tuesday, Thursday, and Saturday at a dialysis center, with diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis. However, the resident’s Quarterly MDS assessments with ARDs of 1/6/26 and 4/1/26 were both not coded to reflect dialysis in Section O. During interview, the MDS Nurse confirmed the resident received dialysis services three times weekly and stated the resident was not coded for dialysis on the two quarterly MDS assessments because all three communication sheets from the dialysis center were unavailable during the 7-day look-back period. The MDS Nurse also confirmed the resident attended and received dialysis on all scheduled days during the look-back period. The Administrator stated that if the resident was receiving dialysis services, the MDS should accurately reflect that. The resident’s MDS with ARD of 4/1/26 also showed a BIMS score of 11, indicating moderate cognitive impairment.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan with measurable objectives and timetables for three residents. For one resident with Alzheimer's disease and severe cognitive impairment, staff observed the resident lying in bed with oily, matted, tangled hair, a foul odor, and a foul odor in the room. A CNA confirmed the resident's hair was unclean and stated the resident needed assistance with soap and shampoo because he would stand in the shower and let the water splash him without awareness to bathe his body or shampoo his hair. The Administrator also confirmed the hair had not been washed and was unclean, and the MDS Nurse stated the resident's care plan was not implemented for shower assistance because he had been marked as independent. For another resident with unspecified dementia, muscle weakness, and need for assistance with personal care, the care plan included bathing/showering intervention to provide a sponge bath when a full bath or shower could not be tolerated. However, observations showed the resident lying in bed with uncombed, matted, tangled hair and visible yellowish, dry, flaky buildup across the front scalp area consistent with lack of washing, and an LPN confirmed the hair was unclean with visible residue and buildup. For a third resident, the care plan report contained no smoking care plan even though the MDS indicated the resident currently used tobacco, the resident stated he was a smoker, and the MDS Nurse confirmed a smoking care plan should have been developed but had not been, stating the omission occurred in error.
Failure to Provide Hair Care and Shampooing Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for hair care and shampooing received the hygiene services needed to maintain personal cleanliness and grooming. Facility policy stated that residents unable to carry out activities of daily living independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During observation, Resident #10 was found lying in bed with oily, matted, and tangled hair, along with a foul odor in the resident and the room. A CNA confirmed the hair was unclean and stated the resident needed aide assistance with soap and shampoo because he would stand in the shower and let the water splash him. The Administrator also confirmed the hair had not been washed and was unclean. Resident #10 was admitted with Alzheimer's Disease and had a BIMS score of 1, indicating severe cognitive impairment. Resident #40 was observed lying in bed with uncombed, matted, and tangled hair, and visible yellowish, dry, flaky buildup on the front scalp area consistent with lack of washing. An LPN confirmed the visible hair residue and buildup and stated that shampooing was part of bathing and should be completed by the aide on the resident's scheduled bath days. The Administrator also confirmed the hair had not been washed and was unclean. Resident #40 was admitted with diagnoses including unspecified dementia, muscle weakness, and need for assistance with personal care, and had a BIMS score of 3, indicating severe cognitive impairment.
Improper Perineal Care During Incontinence Care
Penalty
Summary
Improper perineal care was observed for one resident during a surveyor observation of care. During perineal care for Resident #45, the CNA cleansed the front perineal area, then turned the resident onto her side and found that the resident had a bowel movement. The CNA re-dipped previously used washcloths into the same water basin after it had been used to clean the bowel movement and then used that same water to cleanse the back perineal area. The aide stated before leaving the room that she realized the practice was incorrect. The CNA later confirmed she reused washcloths while providing care because she was out of clean supplies and acknowledged she should have stopped to get additional supplies. She also stated that the improper perineal care increased the resident's risk for spread of bacteria and urinary tract infection. The DON confirmed the aide should have obtained additional clean washcloths to prevent the spread of germs. Resident #45 was admitted with diagnoses including epilepsy and need for assistance with personal care, had a BIMS score of 11 indicating moderate cognitive impairment, and was always incontinent of bowel and bladder.
Failure to Ensure Residents Are Treated with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as required by their own policy and federal regulations. Multiple residents and their representatives reported that certain Certified Nurse Aides (CNAs) displayed rude, abrupt, and unfriendly behavior. Specifically, three residents described negative interactions with CNA #1, including being spoken to in a snappy or gruff tone, being told to perform tasks they were unable to do due to their physical limitations, and generally feeling that the aide was not kind or considerate. These residents had varying medical conditions, such as cerebral infarction, hemiplegia, orthopedic aftercare, and required assistance with personal care, with cognitive assessments indicating that at least two were cognitively intact and able to report their experiences. Staff interviews corroborated the residents' accounts, with several employees and nurses acknowledging that CNA #1 had a reputation for being abrupt, loud, and unfriendly, though not physically abusive. The Director of Nursing (DON) and Administrator were aware of these complaints and had previously spoken to CNA #1 about her tone and demeanor, noting that disciplinary action had been taken in the past for similar grievances. Additionally, another CNA (CNA #3) was reported and disciplined for being loud, rude, and cursing in the hallway, including in the presence of residents and their families. Documentation showed that CNA #3 had a history of similar incidents, including being suspended and later terminated after repeated complaints and investigations. Observations by the surveyor further confirmed the unprofessional conduct, such as a CNA responding to questions in a rude manner and displaying an unapproachable demeanor. The DON and Administrator acknowledged the ongoing issues with staff behavior and confirmed that residents have the right to be treated with respect and kindness. The facility's failure to address these repeated concerns and ensure all residents are treated with dignity resulted in a deficiency related to resident rights and dignity.
Inaccurate PBJ Submission Leads to Low Weekend Staffing Trigger
Penalty
Summary
The facility failed to accurately submit the Payroll-Based Journal (PBJ) for the 4th quarter of the fiscal year 2024. A review of the facility's policy on reporting direct-care information revealed that staffing and census information must be reported electronically to CMS through the PBJ system, including data on staff hired directly, through an agency, and contract employees. The PBJ Staffing Data Report indicated that the facility triggered for low weekend staffing during this period. In an interview, the Director of Nursing (DON) and the Administrator confirmed that the facility was heavily reliant on agency nursing staff during this time, and some agency staff hours were not accurately submitted to the PBJ, leading to the low weekend staffing trigger.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for five residents, as observed and confirmed through interviews and record reviews. Resident #15 was found with facial hair that had not been addressed since her admission, despite her preference for hair removal. Both a CNA and an RN Supervisor acknowledged that facial hair should be managed during bath or shower times. Resident #71 had long, jagged fingernails that had not been trimmed since his admission, which he expressed a desire to have cut. The CNA and RN Supervisor confirmed the need for regular nail care to prevent potential injuries and infections. Resident #31 was observed with excessively long fingernails and facial hair, which he wanted to be trimmed and shaved, respectively. Despite previous refusals, the DON emphasized the importance of offering grooming services regularly. Resident #55 also had long, jagged fingernails, which he preferred to be shorter. A CNA confirmed that nail care should be part of daily hygiene routines to prevent skin tears. Resident #67 had a dark brown substance under her fingernails, suspected to be feces, indicating a lack of recent nail care and hand hygiene. The LPN and CNA acknowledged the infection control concerns associated with this deficiency. The facility's policy on supporting activities of daily living, revised in March 2018, states that residents unable to perform these activities independently should receive necessary services to maintain grooming and hygiene. However, the observations and interviews revealed that the facility did not adhere to this policy, resulting in unmet personal hygiene needs for the residents involved. The deficiencies were confirmed by various staff members, including CNAs, an RN Supervisor, and the DON, highlighting a systemic issue in the facility's care practices.
Failure to Obtain Level II PASARR Status Change After Psychiatric Stay
Penalty
Summary
The facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) status change for a resident following an inpatient psychiatric hospital stay. This deficiency was identified for one of the three PASARRs reviewed. The facility's policy, which follows the PASRR Rules of the Mississippi Division of Medicaid, requires a Level 2 PASRR evaluation to ensure residents receive appropriate psychiatric care. However, the former Social Services Director did not submit a new change of status form for the Level 2 PASARR, mistakenly believing that a negative Level I Preadmission Screening exempted the resident from further submissions. Resident #57 was admitted to the facility with diagnoses including Parkinsonism, Anxiety Disorder, Bipolar II Disorder, and Major Depressive Disorder, Recurrent. The resident's Minimum Data Set indicated a discharge status to an inpatient psychiatric facility. During interviews, the former Social Services Director acknowledged the oversight, and the Administrator confirmed that a change in status form should have been completed after the resident's psychiatric hospital stay. This oversight resulted in the failure to ensure the resident received the necessary psychiatric care evaluation.
Failure to Maintain Functioning Pressure Redistribution Mattress
Penalty
Summary
The facility failed to provide necessary services to promote healing and prevent the development of new pressure ulcers for a resident with existing wounds. The resident, who was admitted with a diagnosis of Huntington's Disease, was observed lying on a deflated air mattress, which was supposed to be a low air loss mattress for pressure redistribution. The air mattress control box was found to be off, and the mattress was completely deflated, causing the resident to lie in a sunken area of the bed. Despite the presence of staff, the deflated mattress was not reported or addressed in a timely manner. A CNA admitted to noticing the deflated mattress earlier in the morning but did not report it. An LPN confirmed the mattress was deflated and could not turn on the control box. The Maintenance Director later confirmed the control box was off and turned it on, inflating the mattress. The DON acknowledged that the resident's condition could worsen due to lying on a deflated mattress and confirmed that the CNA should have reported the issue immediately.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were safely and securely stored, as evidenced by an incident involving Resident #72. On one of the survey days, a Licensed Practical Nurse (LPN) prepared and delivered ten pills to Resident #72, leaving them on the over bed table at the resident's request. The LPN did not remain in the room to observe the resident taking the medication, which is against the facility's policy. This action was confirmed by the LPN, who acknowledged that leaving medications unattended could lead to other individuals accessing them or the resident taking them at an inappropriate time. The incident was further corroborated by a Registered Nurse (RN) Supervisor and the Director of Nursing (DON), both of whom confirmed that the facility's policy requires nurses to observe residents taking their medications to prevent potential misuse or errors. Resident #72, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had been admitted with diagnoses including Major Depressive Disorder and Anxiety Disorder. The failure to adhere to medication administration protocols posed a risk of medication errors or unauthorized access by others.
Failure to Implement ADL Care Plans for Residents
Penalty
Summary
The facility failed to implement Activities of Daily Living (ADL) care plans for five residents who were dependent on staff for assistance with personal hygiene. These residents included individuals with various cognitive impairments and physical limitations, such as weakness, impaired mobility, and poor balance. The care plans for these residents specified that they required assistance with personal hygiene tasks, including shaving and nail care, which were not adequately provided by the facility staff. Resident #15, who had moderate cognitive deficits and required assistance with personal hygiene, was observed with facial hair that had not been shaved since her admission. Similarly, Resident #71, with moderate cognitive deficits, had long, jagged fingernails that had not been trimmed as per his care plan. Resident #31, with severe cognitive impairment, also had long fingernails and facial hair that had not been addressed, despite his requests for assistance. Additionally, Resident #55 and Resident #67, both with cognitive impairments and physical limitations, were found with long, untrimmed fingernails. The staff confirmed that these residents' care plans, which included regular nail care on bath days, were not followed. The observations and interviews with staff and residents highlighted the facility's failure to adhere to the care plans, resulting in unmet personal hygiene needs for these residents.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for its residents, as evidenced by the condition of wheelchairs used by three residents. Observations and interviews revealed that the wheelchairs were dirty, with a thick gray substance on the frames and spokes of the wheels. One resident's wheelchair also had cracked wheels. The facility's policy requires that resident-care equipment be cleaned and disinfected according to CDC recommendations, but this was not adhered to in practice. Interviews with staff, including a CNA and the Director of Nurses, confirmed that the responsibility for cleaning wheelchairs lies with the night shift aides, who are supposed to follow an assignment sheet. However, there was no sign-off sheet to document when the cleaning was completed. The Director of Nurses and the Administrator acknowledged the issue, confirming that the wheelchairs were indeed dirty and some required repairs. The residents involved had various medical conditions, including respiratory failure, heart failure, and cerebrovascular disease, and were either moderately cognitively impaired or cognitively intact.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to document and address grievances raised by a resident and their family, as required by their grievance policy. The policy mandates that grievances can be submitted in various forms and should be investigated by the Grievance Officer, with findings communicated to the complainant. However, the facility's grievance log showed no entries for the resident in question, despite multiple complaints being made. The resident's husband reported having six meetings with the administrator about issues such as the resident being left wet or dirty for extended periods, yet no formal grievance documentation was completed. Interviews with staff, including the Director of Rehab, a Registered Nurse, and the Director of Nurses, confirmed that the resident's family frequently voiced complaints. The Director of Rehab recalled an instance where the resident needed changing before therapy, and the RN reported a complaint about noise disturbances. Despite these issues being brought to the attention of the administrator and the Director of Nurses, neither completed a formal grievance form or ensured proper follow-up, resulting in a failure to resolve the grievances effectively.
Failure to Implement Comprehensive Care Plan for Incontinent Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was implemented for Resident #1, who was incontinent of bladder. The care plan required that the resident be checked every two hours for incontinence episodes. However, observations revealed that Resident #1 was not checked as required. At 10:50 AM, the resident was found lying in bed with a wet and saggy incontinent brief, emitting a mild odor of urine. Further observation at 11:20 AM confirmed that the brief was soaked with urine, and the resident stated he had not been changed since before breakfast. CNA #1 confirmed that the resident had not been changed since the last shift left at 7 AM that morning. Interviews with the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) Nurse confirmed that CNAs were supposed to round on residents every two hours and report any refusals of care to the nurse. The MDS Nurse emphasized that the care plan was designed to identify the care each resident needed and put individualized interventions in place. The failure to check on Resident #1 every two hours as required by the care plan indicated that the care plan was not followed, leading to the deficiency.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to ensure Activities of Daily Living (ADL) care was completed for a dependent resident. During an observation, Resident #1 was found lying in bed with a wet and sagging incontinent brief, emitting a mild odor. The resident confirmed that he had not been changed since before breakfast, and CNA #1 admitted that she had not changed him since the last shift left at 7 AM because he was sleeping. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that CNAs are required to check on residents every two hours, even if they are asleep, to prevent skin breakdown and other complications. Resident #1, who has diagnoses including Huntington's Disease, Spina Bifida, and a Stage 3 Pressure Ulcer of the Right Hip, was left wet for an undetermined amount of time. The ADON and DON both emphasized that it is unacceptable for a CNA to leave a resident without checking and changing them for over four hours. The facility policy requires that residents who are unable to carry out ADLs independently receive the necessary services to maintain good nutrition, grooming, and personal hygiene, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Corinth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ms Care Center Of Alcorn County, Inc-snf | 0.2 mi | ★★★★★ | 10 | 0 |
| Selmer Post Acute | 15.8 mi | ★★★★★ | 0 | 0 |
| Landmark Nursing And Rehab Center | 19.3 mi | ★★★★★ | 1 | 0 |
| Longwood Community Living Center | 19.4 mi | ★★★★★ | 9 | 0 |
| Tishomingo Manor | 20.7 mi | ★★★★★ | 1 | 0 |
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