Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Graceland Rehabilitation And Nursing Care Center during CMS and state inspections, most recent first.
Two residents experienced significant harm due to staff failing to follow required safety protocols. In one case, a cognitively impaired, non-verbal resident who required two-person assist for bed mobility was left with only one CNA during repositioning, resulting in a fall from bed and traumatic brain injury. In another case, a resident with mobility issues and cognitive impairment suffered an unwitnessed fall, complained of severe pain and immobility, but was moved and left waiting over six hours for hospital transport, later being diagnosed with a hip fracture.
Surveyors identified multiple failures in food storage, preparation, and sanitation, including unlabeled and undated food, unclean equipment with rust and buildup, improper temperature monitoring, and inadequate dishwashing practices. Staff did not consistently follow procedures for cleaning, labeling, and temperature control, and communication lapses contributed to ongoing unsanitary conditions affecting meal service to over 130 residents.
Staff, including LPNs and housekeeping, did not consistently use PPE or perform hand hygiene when entering or exiting rooms of residents on contact isolation for Candida Auris. A resident on contact precautions was also allowed to leave their room and interact with others without proper PPE. Staff interviews confirmed lapses in understanding and compliance with infection control protocols.
The facility did not obtain required consent for the administration of psychotropic medications for two residents, one with severe cognitive impairment and another with no cognitive impairment, both of whom received antipsychotic and antidepressant medications without documented consent from themselves or their representatives. Staff interviews confirmed that consent procedures were not followed as required by facility policy.
The facility did not provide or document required education and written information about advance directives for multiple residents, regardless of their cognitive status or medical conditions. Review of medical records showed consistent lack of documentation, and staff confirmed that no process was in place for advance directive education prior to the survey.
A resident with a history of mental health conditions received PRN Ativan for anxiety well beyond the 14-day policy limit, without a documented physician assessment or rationale for continued use. Facility staff, including the SSD, MD, and pharmacist, were unaware of the extended orders and did not provide documentation to justify the ongoing administration. The facility's policy requiring a 14-day limit and documented rationale for PRN psychotropic medications was not followed.
A resident with a history of falls and moderate cognitive impairment was found on the floor after calling for help, later diagnosed with a right femoral fracture. The facility did not submit a complete investigation report to the state agency, leaving required sections blank and failing to provide sufficient details about the investigation or actions taken, contrary to facility policy.
A resident with severe cognitive impairment was discharged to a psychiatric care facility without the required notification to their representative. The Social Services department did not inform the representative of the discharge or the receiving facility's refusal to accept the resident back, and this communication was not documented in the medical record, contrary to facility policy.
The facility did not obtain required laboratory tests as ordered by physicians for two residents, including missing HgbA1C, CK, and PSA tests for residents with diabetes and other complex conditions. Facility leadership confirmed that these labs were not completed as ordered.
A medication cup containing eight pills was found left unsecured and unattended on the dresser of a resident with severe cognitive impairment. An LPN not assigned to the resident was unaware of the medications, and both the LPN and DON confirmed that medications should not be left at the bedside.
The facility failed to provide adequate hot water for bathing, affecting five residents due to water temperatures below the required 105°F to 115°F range. Despite being aware of the issue, the maintenance department did not inform the Administrator, leading to a delay in resolution. The affected residents, with various medical conditions, were unable to take showers or baths due to the cold water.
A resident with severe cognitive impairment and high fall risk was not provided the required two-person assist during care, leading to a fall. The CNA attempted to change the resident without assistance, contrary to the care plan. The incident was confirmed by the LPN and DON, highlighting a failure to follow the facility's policies on care plans and fall prevention.
A resident with multiple risk factors for skin conditions did not receive accurate weekly skin assessments, as required by facility policy. The documentation process was flawed, with only check marks used instead of the required coding system, leading to undetected diabetic foot ulcers. Interviews with staff and a family member revealed communication gaps and a lack of proper documentation.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents who required assistance with mobility and activities of daily living. In the first incident, a non-verbal, cognitively impaired resident who was totally dependent on staff for mobility and required two-person assistance with bed mobility was being repositioned by two CNAs. One CNA left the room to retrieve additional supplies, leaving the other CNA alone with the resident, who was still positioned on her side. The resident's weight shifted, causing her to fall from the bed and sustain a significant head injury, resulting in a traumatic brain injury and hospitalization. Both CNAs and facility leadership confirmed that the resident was known to require two-person assistance and that the policy was not followed when one CNA left the room during care. In the second incident, another resident with moderate cognitive impairment, Parkinson's disease, muscle weakness, and a history of repeated falls was found on the floor after an unwitnessed fall. The resident complained of severe pain and inability to move her right leg, and requested an x-ray. Staff assisted the resident to bed and then used a mechanical lift to transfer her to a wheelchair, despite her complaints of pain and immobility. There was a delay of over six hours before emergency transport was called to take the resident to the hospital, where she was diagnosed with a displaced subcapital right femoral neck fracture. Interviews revealed that staff did not immediately call 911 and moved the resident despite her symptoms, contrary to expected protocol. The facility's policies required two-person assistance for certain residents and outlined procedures for responding to falls and pain management. However, in both cases, staff failed to follow these protocols, resulting in significant harm to the residents. The incidents were confirmed through medical record review, staff and family interviews, and facility investigations, and led to the identification of Immediate Jeopardy due to the serious injuries sustained by the residents.
Removal Plan
- Educated CNA A and CNA B on 2-person assist with bed mobility and positioning and repositioning the resident while providing care.
- Reviewed all falls, policies, Kardex's and care plans to align with each resident's current bed mobility needs.
- Began in-servicing on Fall Management Program, Safety and Supervision of the Resident, and Positioning and Repositioning of the resident for all licensed Nurses, CNAs, and Respiratory Therapist.
- Implemented Fall audits, Care plan audits, Kardex audits, Policy audits, and on-going education with Licensed Nurses, CNAs, and Respiratory Therapist on 2-person assist with bed mobility to call for help and not leave the room if they need any supplies.
- Conducted skills competency with positioning and repositioning residents with return demonstration to prevent recurrence.
- Monitoring all falls daily.
- Ensuring all care plans and Kardex's are up to date.
- Ongoing competencies and education to ensure training is effective.
- Measuring effectiveness of the in-services by monitoring the falls on a daily basis and observing return demonstrations through competency.
- Conducted a facility wide fall audit with no major injuries.
- Conducted a facility wide care plan audit to ensure any resident that is a 2-person assist reflects accurately and was found to be up to date.
- Conducted a facility wide Kardex audit to ensure all residents had an up-to-date Kardex and aligning with current care plan with 2-person assist with bed mobility.
- Reviewed policies on Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by the Administrator and Director of Nursing with no revisions needed.
- In-serviced all licensed Nurses, CNAs, Respiratory Therapist, any nursing agency personnel and any Nurses, CNAs, Respiratory Therapist on Leave of Absence (LOA) on Fall Prevention, Safety and Supervision of Residents, and Repositioning.
- Continuing ongoing Quality Assurance Plan to monitor facility performance and compliance with the Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by continuing to monitor falls daily and implementing planned interventions and approaches appropriately.
Widespread Food Sanitation and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, handled, prepared, and served under sanitary conditions, as evidenced by multiple observations of unsanitary practices and unclean equipment in the kitchen and food storage areas. Surveyors observed rust and black buildup on stainless steel tables and storage racks, a rust-colored substance inside the ice machine, and dust and rust around ceiling vents and coolers. Food items were found opened, undated, and uncovered on tables and racks, and several trays of prepared food in the reach-in cooler were unlabeled and undated. Dry ingredient storage bins containing sugar and flour were also unlabeled, undated, and had soiled lids with thick yellow sticky debris. Additionally, utensils such as a can opener had thick black buildup, and a serving spoon was found with dried unidentified residue. Temperature control and monitoring were also deficient. The ice cream freezer and milk cooler lacked thermometers, and temperature logs were not properly maintained. Staff were unable to explain how temperatures were being recorded without thermometers present. During tray line service, staff failed to use a clean alcohol pad between taking temperatures of different food items, which was confirmed by dietary staff as not following proper procedure. The high-temperature dish machine was not reaching appropriate sanitizing temperatures, and staff were not consistently informed to use paper products or the three-compartment sink as an alternative while the machine was out of order. Meals continued to be served on regular dishware despite the dish machine malfunction. Interviews with dietary staff, the maintenance director, the registered dietician, and the administrator confirmed a lack of communication and understanding of proper procedures regarding equipment sanitation, temperature monitoring, and food labeling. Staff were unclear about the type of dish machine in use and the required sanitizing temperatures. The registered dietician and administrator were not promptly informed of the dish machine malfunction, and dietary staff acknowledged lapses in following established policies for food safety and sanitation. The facility census at the time was 158, with 133 residents receiving meals from the kitchen.
Failure to Follow Infection Control Protocols for Residents on Contact Isolation
Penalty
Summary
Staff failed to follow proper infection prevention and control practices for residents on contact isolation precautions for Candida Auris. Observations revealed that both nursing and housekeeping staff entered rooms of residents under contact isolation without donning required PPE such as gowns and gloves. Staff were also seen touching medical equipment and resident environments without appropriate PPE and then exiting rooms without performing hand hygiene, contrary to facility policy and physician orders. Multiple residents with severe cognitive impairment and total dependence on staff for activities of daily living were affected, as well as a resident with no cognitive impairment. One resident on contact isolation was observed outside of his room in a communal area without wearing the required isolation gown, and staff interviews confirmed that this resident was sometimes allowed to leave his room without proper PPE due to non-compliance. Housekeeping staff also entered and cleaned rooms of residents on contact isolation without PPE and failed to perform hand hygiene after exiting, indicating a lack of adherence to established infection control protocols. Interviews with staff, including LPNs and housekeeping, revealed a lack of understanding or compliance with the requirements for PPE use and hand hygiene when caring for residents on contact precautions. The Director of Nursing and the Administrator confirmed that all staff should follow transmission-based protocols for residents with Candida Auris, including the use of PPE and hand hygiene, but these protocols were not consistently implemented.
Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain consent for the administration of psychotropic medications for two of five sampled residents reviewed for unnecessary medications. Facility policy requires that residents, families, and/or representatives be involved in the medication management process, and that psychotropic medications are not administered unless clinically indicated and with proper documentation. However, review of medical records and interviews revealed that consent was not obtained for the use of antipsychotic and antidepressant medications for two residents. One resident with severe cognitive impairment and diagnoses including psychosis and dementia was prescribed and administered Seroquel and Zoloft. Medical records showed ongoing use of these medications, but there was no documentation of consent from the resident's family or representative. In a telephone interview, the resident's family member stated they were unaware of the medications being administered. Another resident, who was cognitively intact and diagnosed with bipolar disorder, depression, and anxiety, received multiple psychotropic medications including Ativan, Risperidone, and Trazodone. Medical record review confirmed frequent administration of these medications, but again, no consent forms were found. Interviews with facility staff, including the Social Service Director and DON, confirmed that consents for psychotropic medications had not been obtained for these residents at the time of review.
Failure to Provide Advance Directive Education and Documentation
Penalty
Summary
The facility failed to provide education and written information regarding advance directives to residents and/or their representatives, as required by policy. Policy review indicated that the social services director or designee is responsible for inquiring about the existence of advance directives and providing written information to residents or their representatives prior to or upon admission. However, for 27 out of 35 sampled residents, there was no completed documentation in the medical records to show that this education or information was provided. The deficiency was identified through a combination of policy review, medical record review, and staff interview. Medical records for the affected residents, who had a range of diagnoses including diabetes, dementia, chronic respiratory failure, anoxic brain injury, and other serious conditions, consistently lacked documentation of advance directive education. The cognitive status of these residents varied, with some being severely cognitively impaired, some moderately impaired, and others cognitively intact, as indicated by their BIMS scores or clinical assessments. Regardless of cognitive status, the required documentation was missing for all identified residents. During an interview, the Marketing Director confirmed that there was no process in place for educating residents or their representatives about advance directives prior to the week before the survey. This lack of process contributed to the widespread absence of documentation and failure to meet the facility's policy and regulatory requirements regarding residents' rights to formulate advance directives.
Failure to Limit PRN Psychotropic Medication Duration and Document Rationale
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications for a resident were limited to a 14-day duration, as required by facility policy. Specifically, a resident with diagnoses including Bipolar Disorder, Depression, and Anxiety Disorder received PRN Ativan (an antianxiety medication) for longer than 14 days without a documented physician assessment or rationale for continued use. The resident's medical record showed frequent administration of Ativan over several months, with no evidence of a stop date or justification for extending the PRN order beyond the policy limit. Additionally, the resident had two PRN orders for different antianxiety medications (Ativan and Diazepam), but only Ativan was administered during the review period. Interviews with facility staff, including the Social Service Director, Medical Director, and Pharmacist, revealed a lack of awareness and documentation regarding the rationale for the extended PRN orders. The Social Service Director was unaware of the orders exceeding 14 days, and the Pharmacist indicated uncertainty about the need for a stop date. The Medical Director deferred responsibility to the hospice physician, but no documentation from hospice provided a rationale for the ongoing PRN use. The facility's failure to follow its own policy and federal regulations regarding PRN psychotropic medication orders resulted in the deficiency.
Failure to Submit Complete Investigation Report for Injury of Unknown Origin
Penalty
Summary
The facility failed to report sufficient information regarding the results of an investigation into an injury of unknown origin for one resident. According to facility policy, all incidents of abuse, neglect, or injuries of unknown source must be promptly and thoroughly investigated, with a written report of the investigation results and any actions taken submitted to the state survey agency within five working days. However, review of the Incident Reporting System (IRS) and related documentation revealed that the facility did not submit a final investigation report with adequate details describing the results of the investigation or any corrective actions taken. The resident involved had a history of Parkinson's Disease, lack of coordination, muscle weakness, repeated falls, and moderate cognitive impairment. The care plan identified the resident as being at risk for falls, with interventions such as ensuring the call light was within reach and encouraging the resident to call for assistance. On the day of the incident, the resident was found on the floor after calling for help, complaining of pain in the right hip and leg. The resident was subsequently transferred to the emergency room, where a right femoral fracture was identified. Despite the incident being reported in the IRS and a follow-up submission noting the injury, the facility's report to the state agency lacked sufficient information about the investigation process, findings, and any actions taken. The IRS entry for the investigation was left blank, and the follow-up submission contained only a single sentence without details of interventions or investigative outcomes. Interviews with state agency staff and the facility administrator confirmed that a final investigation report was not submitted as required by policy.
Failure to Notify Resident's Representative of Discharge Decision
Penalty
Summary
The facility failed to notify a resident's representative or family member of the intent to discharge, as required by facility policy. The policy states that in the event of an emergency transfer or discharge, the representative or family member must be notified. In this case, a resident with severe cognitive impairment, as indicated by a BIMS score of 8, was discharged to a psychiatric care facility. Documentation in the medical record showed the resident was transported in stable condition, and the receiving facility communicated that the resident could not return due to elopement risk and the need for a secure unit. Despite these events, the resident's representative confirmed during an interview that she was unaware of the facility's decision to discharge and the refusal to accept the resident back. Both the Social Services Director and the Director of Nursing acknowledged that Social Services was responsible for informing the representative and that this communication should have been documented in the medical record. The lack of notification and documentation constituted a failure to follow the facility's discharge procedures.
Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
The facility failed to follow physician orders and obtain required laboratory work for two residents reviewed for unnecessary medication use. For one resident with diagnoses including diabetes, urinary tract infection, and colostomy, the facility did not obtain a Hemoglobin A1C (HgbA1C) test in March as ordered by the physician, despite documentation in the care plan and physician orders specifying the need for quarterly lab monitoring. This resident was also noted to be severely cognitively impaired and receiving hypoglycemic medications. For another resident with multiple diagnoses including malignant neoplasm of the colon, diabetes, vitamin D deficiency, anemia, convulsions, and hypertension, the facility failed to obtain a Creatine Kinase (CK) level and a Prostate-Specific Antigen (PSA) level as ordered for October, and did not obtain a HgbA1C level as ordered for February. The care plan and physician orders for this resident specified the need for these labs at regular intervals, but the medical record did not show evidence that these labs were completed as required. Facility leadership confirmed during interviews that labs should be obtained according to physician orders.
Unsecured Medications Left Unattended in Resident Room
Penalty
Summary
Medications were found unsecured and unattended in a resident's room, contrary to facility policy requiring all drugs and biologicals to be stored safely and securely. A resident with severe cognitive impairment, as indicated by a BIMS score of 5 and diagnoses including diabetes, Alzheimer's disease, depression, and hypertension, was observed to have a medication cup containing eight pills left on their dresser during two separate observations. An LPN, who was not assigned to the resident, confirmed she was unaware of the medications and acknowledged that medications should not be left at the bedside. The Director of Nursing also confirmed that medications should not be left at the bedside.
Failure to Provide Adequate Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide reasonable accommodations for the bathing needs of five residents due to inadequate hot water temperatures. The facility's policy and state regulations require hot water to be available at temperatures between 105°F and 115°F at all times. However, observations and interviews revealed that the water temperatures in resident rooms ranged from 80°F to 104°F, which is below the required standard. This deficiency affected residents who were unable to take showers or baths due to the cold water, as confirmed by their statements during interviews. The issue was documented in the Resident Council Minutes and QAPI Minutes, indicating that the problem persisted over several months without resolution. Despite the maintenance department being aware of the issue, the Administrator was not informed until later, which contributed to the delay in addressing the problem. The affected residents had various medical conditions, including diabetes, hemiplegia, and chronic kidney disease, and were either cognitively intact or moderately impaired, as indicated by their BIMS scores.
Failure to Follow Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to adhere to the comprehensive person-centered care plan for a resident identified as high fall risk, which resulted in a deficiency. The care plan, which was revised to include a two-person assist for bed mobility, was not followed when a CNA attempted to provide care to the resident without assistance. This action led to the resident being slid to the floor, although no injuries were noted. The incident was documented in the facility's Incident Audit Report and confirmed by the LPN who was present in the hallway at the time. The resident involved had a history of severe cognitive impairment, as indicated by a BIMS score of 3, and was admitted with multiple diagnoses, including chronic respiratory failure and osteopenia. The Director of Nursing confirmed that the staff did not follow the care plan during the incident. The facility's policies on comprehensive care plans and fall prevention emphasize the need for staff to be informed of their roles and responsibilities, which were not adhered to in this case.
Inadequate Documentation of Skin Assessments Leads to Undetected Wounds
Penalty
Summary
The facility failed to accurately document skin assessments for a resident with wounds, as required by their policy on the prevention of pressure injuries. The policy mandates a comprehensive skin assessment upon admission, weekly, and upon any changes in condition, using a standardized pressure injury screening tool. However, the facility's documentation for the resident's weekly skin evaluations was inconsistent and did not accurately reflect the resident's skin condition, as evidenced by the use of check marks instead of the required coding system to indicate skin impairment, pre-existing conditions, or new areas of concern. The resident in question was admitted with multiple diagnoses, including cerebral infarction, diabetes, and morbid obesity, which increased their risk for skin conditions. Despite these risk factors, the facility's records showed that the weekly skin evaluations were not properly documented from October 2024 through January 2025. During this period, the resident developed two diabetic foot ulcers, which were not identified until late November 2024, when they were found to be necrotic. This indicates a failure in the facility's process for monitoring and documenting skin conditions, as the ulcers were not noted in the weekly evaluations prior to their discovery. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that the documentation process was flawed, with only check marks being used to indicate that an assessment was done, rather than the specific coding required by the facility's policy. Additionally, a family member of the resident expressed concern about not being informed of the wounds, highlighting a communication gap between the facility and the resident's family. The Director of Nursing confirmed the lack of proper documentation and acknowledged that the weekly skin evaluations should have been marked according to the established coding system.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkway Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 1 | 0 |
| Diversicare Of Southaven | 4.7 mi | ★★★★★ | 12 | 1 |
| Delta Blues Health & Rehabilitation | 4.8 mi | ★★★★★ | 7 | 1 |
| Desoto Healthcare Center | 5.2 mi | ★★★★★ | 3 | 0 |
| Allen Morgan Health And Rehabilitation Center | 6.3 mi | ★★★★★ | 2 | 0 |
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