COMMUNITY PLACE
Non profit - Other
60 Beds
Independent
Data: November 2025
Trust Grade
55/100
#64 of 200 in MS
Photo by Community Place Nursing Home
Photo by Curtis Everitt
Photo by Community Place Nursing Home
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Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Community Place in Brandon, Mississippi, has a Trust Grade of C, which means it is average and sits in the middle of the pack for nursing homes. It ranks #64 out of 200 facilities in the state, placing it in the top half, but only #6 out of 9 in Rankin County, indicating there are better local options. Unfortunately, the facility's trend is worsening, with issues increasing from 3 in 2023 to 10 in 2025. Staffing here is a concern, with a 98% turnover rate, significantly higher than the state average, which may affect continuity of care. On a positive note, they have not incurred any fines, and the RN coverage is average, although specific incidents have raised flags, such as failing to ensure that advance directives were documented for several residents, a lack of privacy for a resident with a urinary catheter, and not providing a shower chair for a resident who needed one. Overall, while there are strengths, such as no fines, serious concerns about staffing and care practices suggest families should weigh their options carefully.
- Trust Score
- C
- In Mississippi
- #64/200
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 98% turnover. Very high, 50 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Mississippi facilities.
- Skilled Nurses ✓ Good
- Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Mississippi. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Top 32%
No red flags
3 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 3 issues
2025: 10 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Mississippi average (2.6)
Meets federal standards, typical of most facilities
Staff Turnover: 98%
52pts above Mississippi avg (47%)
Frequent staff changes - ask about care continuity
Staff turnover is very high (98%)
50 points above Mississippi average of 48%
The Ugly 15 deficiencies on record
Jan 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident's right to a dignified existence related to a urinary catheter drainage bag that did...
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Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident's right to a dignified existence related to a urinary catheter drainage bag that did not have a privacy covering for one (1) of three (3) residents reviewed for catheters. (Resident #16)
Findings included:
A review of the facility's policy, Resident Rights, undated, revealed, .Policy Interpretation and Implementation .1. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a. a dignified existence .
On 01/14/2025 at 8:12 AM, during an observation, Resident #16 was in bed and there was a catheter drainage bag that was positioned on the right-hand side of the bed facing the door, with no privacy cover. The urine in the drainage bag was visible from the open door.
On 01/14/2025 at 12:31 PM, during an observation, Resident #16 remained in bed. The urinary drainage bag remained uncovered with yellow urine visible. There was no privacy covering for the drainage bag.
On 01/14/2025 at 12:32 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated he was responsible for Resident #16's care. He explained that a collection bag cover ensures others cannot see the contents of the bag, maintaining the resident's dignity. CNA #1 confirmed the resident did not have a privacy covering on the drainage bag and he immediately retrieved one for the resident.
On 01/14/2025 at 2:14 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed that Resident #16's urinary drainage bag lacked a privacy cover. She stated the catheter bag should always have a privacy cover, per facility policy, to ensure dignity and prevent the collection bag and tubing from contacting the floor.
On 01/16/2025 at 1:27 PM, during an interview, the Assistant Director of Nursing (ADON) stated his expectation was that all nursing staff ensure urinary catheters are managed per facility policy. He emphasized that catheter bags should always have privacy covers to maintain dignity.
A record review of the admission Record revealed the facility admitted Resident #16 on 11/04/2024 with diagnoses including Pressure Ulcer of Sacral Region, Unspecified Stage.
A record review of the Order Summary Report with active orders as of 1/16/2025 revealed a physician's order, dated 09/03/2024, to change the suprapubic (indwelling) catheter on the third (3rd) of each month and as needed.
A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/2024 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review, and facility policy review the facility failed to accommodate the needs and preferences of residents who required adaptive equipment to take a shower f...
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Based on observation, interviews, record review, and facility policy review the facility failed to accommodate the needs and preferences of residents who required adaptive equipment to take a shower for (1) of (23) sampled residents. Resident #1.
Findings Include:
A review of the facility policy, Resident Rights,, undated, revealed, Policy Statement .Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to .h. be supported by the facility in exercising his or her rights .
On 1/14/25 at 10:38 AM, during an interview with Resident #1, he revealed that he would like to take a shower from time to time. He indicated that he was told there is no shower chair available for him, so he has to rely on bed baths.
On 1/15/25 at 9:41 AM, Certified Nursing Assistant #2 (CNA) explained that he has cared for the resident over the past six months. He explains that the facility does not have a shower chair to accommodate his request for a shower but does provide the resident with a bed bath daily.
On 1/16/25 at 10:45 AM, in a phone interview with the mother and Resident Representative (RR), she revealed that a couple of months ago she shared her concern about her son, Resident #1, wanting a shower with the Director of Nursing (DON) and the Administrator. She explained that she was told they would look into getting a bariatric shower chair for him, like the one he had at their old building.
On 1/16/25 at 11:20 AM, in an interview, the Director of Rehabilitation recalled that Resident #1 was evaluated, and it was concluded that, due to his poor upper trunk control, taking showers would not be safe. He mentions that there may be a special chair available for him somewhere with an outside supplier, but he does not know of one.
On 1/16/2025 at 11:37 AM, in an interview with the Administrator, he explained that at the facility's previous building, Resident #1 had a chair he could use for showering. However, it was old, and the decision was made not to bring it to the new building during the move. The Administrator confirmed that Resident #1 should be able to shower whenever he wishes and have the necessary equipment to do so.
On 1/16/2025 at 12:01 PM, during an observation and follow-up interview with the Director of Rehabilitation, the facility's current shower chair was inspected. The Director of Rehabilitation indicated that it could be possible, with further evaluation and additional staff assistance, for Resident #1 to use the current shower chair.
A review of the admission Record reveals the facility admitted Resident #1 on 1/15/1996 with diagnosis including Hemiplegia and Hemiparesis.
A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/6/24 revealed Resident #1 had a Brief Interview Mental Score (BIMS) of 15, indicating the resident was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure that a resident was free from a physical restraint imposed for staff convenience related to fa...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure that a resident was free from a physical restraint imposed for staff convenience related to fall prevention for one (1) of 23 sampled residents. Resident #52.
Findings included:
A review of the facility's policy titled Use of Restraints, revised April 2017, revealed, .Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience or the prevention of falls .
On 01/14/25 at 09:05 AM, during an observation, Resident # 52 was sitting in a wheelchair with a lap table secured to the wheelchair.
On 01/14/25 at 12:23 PM, during an observation of the lunch meal in the dining room, Resident #52 did not have the lap tray attached to her wheelchair. Her posture was stable, and she was not leaning during the meal. A Certified Nurse Aide (CNA) attached a lap tray to Resident #52's chair before she was transported out of the room.
On 01/16/2025 at 3:11 PM, during an interview, CNA #3 who is the Lead CNA, stated the lap tray was used to prevent Resident #52 from falling. She explained that when the resident became agitated, she would beat on the lap tray and yell for help. She stated the lap tray was removed every 15 minutes and when the resident needed toileting. She also noted that most falls occurred on the 3:00 PM to 11:00 PM shift when it was hard to monitor the resident. She added that CNAs did not document lap tray removal every 15 minutes, as it was the nurse's responsibility.
On 01/16/2025 at 3:30 PM, during an interview, CNA #4, who cared for Resident #52 on the 3:00 PM to 11:00 PM shift, stated she only released the lap tray when the resident needed to use the bathroom. She reported the resident had the lap tray on pretty much all the time during her shift. CNA #4 was unaware of the reason for the lap tray but noted she had been told the resident had a history of falls.
On 01/16/2025 at 3:35 PM, during an interview, Licensed Practical Nurse (LPN) #3 stated that before the lap tray was implemented, Resident #52 had required one-on-one (1:1) supervision. She explained that the lap tray was used to prevent the resident from falling and that CNAs were supposed to release it every two hours, as documented on the Electronic Medication Administration Record (EMAR). She also noted that the resident had fallen twice in recent months, including once with the lap tray in place.
On 01/16/2025 at 3:45 PM, during an interview, the Assistant Director of Nursing (ADON) stated the lap tray was used for safety due to Resident #52's history of falls and attempts to get out of her chair. He acknowledged that the resident had fallen with the lap tray in place and that without the lap tray, the facility would be unable to prevent her from falling.
A record review of the admission Record revealed the facility admitted Resident #52 on 08/09/2022 and she had current diagnoses including Parkinson's Disease.
A record review of the Order Summary Report with active orders as of 1/16/2025, revealed Resident #52 had a physician's order, dated 5/20/2024, for a lap tray when in wheelchair, during waking hours, release every two hours for repositioning and activities of daily living (ADL) care.
A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2024 revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of four (4), indicating severe cognitive impairment.
A record review of Resident #52's Lap Tray Checklist, dated 12/18/2024 to 01/16/2025, revealed the lap tray was not documented as being removed every two hours per the physician order.
A record review of Resident #52's Initial Assessment for Application of Restraint, dated 05/14/2024, revealed a history of over 20 falls with head contusions and unsafe attempts to ambulate.
A record review of Resident #52's Physical Restraint Consent, dated 06/10/2024, indicated the use of the lap tray for safety.
A record review of Resident #52's Restraints Physical Quarterly/Annual Evaluation, dated 11/18/2024, indicated the use of restraints was due to unsteady gait, agitated behavior, aggressive behavior, frequent falls, and attempts to self-transfer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to provide nail care to a diabetic resident requiring nail care by a Registered Nurse (RN) for one (1) o...
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Based on observation, interview, record review, and facility policy review, the facility failed to provide nail care to a diabetic resident requiring nail care by a Registered Nurse (RN) for one (1) of 23 residents whose nails were observed. Resident #31.
Findings included:
A review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, undated, revealed, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene .
On 01/14/2025 at 8:29 AM, during an observation, Resident #31 was seated in his wheelchair in his room. His fingernails were noted to be long, dirty, and jagged.
On 01/15/2025 at 12:21 PM, during an observation in the dining room, Resident #31 was seen eating lunch. His fingernails remained long, dirty, and jagged.
On 01/16/2025 at 12:28 PM, during an interview, the Assistant Director of Nursing (ADON) stated that two Registered Nurses are responsible for providing diabetic nail care. He explained that residents' nails are supposed to be cleaned and cut weekly.
On 01/16/2025 at 12:32 PM, during an interview and observation, the ADON examined Resident #31's fingernails. He confirmed that the nails on Resident #31's left hand were dirty and needed to be cleaned. He stated that one hand was clean while the other was not. The ADON acknowledged that nails should not be cut too short but expressed his expectation that nurses clean and cut residents' nails weekly.
A record review of the admission Record revealed the facility admitted Resident #31 on 5/14/2015 and he had current diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia.
A record review of Resident #31's Order summary Report with active orders as of 1/16/2025 revealed a physician's order, dated 12/4/24, for diabetic nail care to be provided by a Registered Nurse (RN) every Wednesday and as needed.
A record review of Resident #31's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident was mildly cognitively impaired. Section GG was coded as dependent for personal hygiene.
A record review of the January 2025 Electronic Treatment Administration Record (ETAR) revealed the RN staff did not document that diabetic nail care was provided on 01/01/2025 or 01/15/2025.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review and facility policy review the facility failed to prevent possible complications related to a resident with an indwelling suprapubic catheter, as e...
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Based on observation, staff interview, record review and facility policy review the facility failed to prevent possible complications related to a resident with an indwelling suprapubic catheter, as evidenced by the catheter drainage bag coming into direct contact with the floor for one (1) of 1 resident reviewed with a catheter. Resident #16
Findings included:
A review of the facility's policy, Catheter Care, Urinary, undated, revealed, .The purpose of this procedure I to prevent catheter-associated urinary tract infections .Infection Control .7 Be sure the catheter tubing and drainage bag are kept off the floor .
During an observation on 01/14/2025 at 8:12 AM, Resident #16 was in bed and there was a catheter drainage bag that was positioned on the right-hand side of the bed facing the door. The drainage bag was touching the floor.
During an observation on 01/14/2025 at 12:31 PM, Resident #16 remained in bed. The urinary drainage bag remained touching the floor in the room.
During an interview on 01/14/2025 at 12:32 PM, Certified Nursing Assistant (CNA) #1 stated he was responsible for Resident #16's care. He explained that a drainage bag privacy cover prevents it from contacting the floor directly, reducing the risk of contamination.
During an interview on 01/14/2025 at 2:14 PM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #16's urinary drainage bag should not be on touching the floor as per the facility's policy.
During an interview on 01/16/2025 at 1:27 PM, the Assistant Director of Nursing (ADON) stated his expectation was that all nursing staff ensure urinary catheters are managed per facility policy. He emphasized that catheter drainage bags and tubing must be positioned to prevent contact with the floor.
A record review of the admission Record revealed the facility admitted Resident #16 on 11/04/2024 with diagnoses including Pressure Ulcer of Sacral Region, Unspecified Stage.
A record review of the Order Summary Report with active orders as of 1/16/2025, revealed Resident #16 had a physician's order, dated 09/03/2024, to change the suprapubic (indwelling) catheter on the third (3rd) of each month and as needed.
A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/2024 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and record review, the facility failed to prevent possible complications related to the storage of a Continuous Positive Airway Pressure (CPAP) mask, for one (1) ...
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Based on observation, staff interview and record review, the facility failed to prevent possible complications related to the storage of a Continuous Positive Airway Pressure (CPAP) mask, for one (1) of two (2) residents reviewed for respiratory. Resident #47
Findings included:
On 1/14/2025 at 8:49 AM, during an interview, Resident #47 stated she uses her CPAP machine nightly. She explained that the mask had never been stored in a designated bag and was left on top of the dresser by her bedside.
On 1/15/2025 at 12:08 PM, during an observation, Resident #47 was eating lunch in her room, and her CPAP mask remained on the table without being stored in a bag.
On 1/15/2025 at 2:32 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed that the mask was not in a designated storage bag on 1/14/2025 or 1/15/2025. She stated the mask should be stored in a bag to prevent it from getting dirty and causing complications.
On 1/15/2025 at 4:15 PM, during an interview, Registered Nurse (RN) #1, the Infection Preventionist, stated the mask should always be stored in a bag to prevent the resident from acquiring an infection.
On 1/15/2025 at 4:18 PM, during an interview, the Assistant Director of Nursing (ADON) stated the CPAP mask should be stored in a bag when not in use. He explained the bag should be labeled with the date, and the mask should be cleaned weekly, placed in a clean bag after cleaning, and the bag replaced weekly to prevent infection.
A record review of the admission Record revealed the facility admitted Resident #47 on 2/28/2023 with diagnoses including Obstructive Sleep Apnea.
A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/2024 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.
Record review of the Order Summary Report with active orders as of 1/16/2025 revealed an order dated 1/15/2025 for CPAP Machine Mask to be placed in bag after each use daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility policy review, the facility failed to ensure medications and a medication cart were locked and secured for one (1) of three (3) medication carts obs...
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Based on observation, staff interview, and facility policy review, the facility failed to ensure medications and a medication cart were locked and secured for one (1) of three (3) medication carts observed.
Findings included:
A review of the facility's policy, Medication Labeling and Storage undated, revealed, .The facility stores all medications and biologicals in locked compartments .
A review of the facility's policy, Administering Medications, undated, policy revealed, .Medications shall be administered in a safe and timely manner as prescribed. Policy Interpretation and Implementation .During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide .No medications are to be kept on top of the cart. The cart must be clearly visible to personnel administering medications, and all outside surfaces must be inaccessible to residents or others passing by .
On 01/14/2025 at 7:40 AM, during an observation, an unattended, unlocked medication cart was noted with an unlabeled white tablet in a medication cup left on top of the cart. The cart remained unattended for approximately three (3) minutes.
On 01/14/2025 at 8:00 AM, during an interview, Licensed Practical Nurse (LPN) #1 stated that she had pulled a medication for a resident and then walked away from her medication cart to respond to another resident, leaving the cart unlocked and out of her sight. She confirmed this action was a safety issue and could lead to potential medication errors.
On 01/16/2025 at 1:27 PM, during an interview, the Assistant Director of Nursing (ADON) stated his expectation during medication administration and storage was that no medications be left on top of carts without full nursing supervision. He also stated that all carts should be locked when not attended by licensed staff. The ADON noted that a resident could access the cart or medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
Based on staff interview and the Facility Assessment review, the facility failed to ensure all required elements were included in the Facility Assessment, including specific staffing needs by shift, a...
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Based on staff interview and the Facility Assessment review, the facility failed to ensure all required elements were included in the Facility Assessment, including specific staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning that do not require activation of the facility's emergency plan for three (3) of (3) days of survey.
Findings Included:
A record review of the facility's Facility Hierarchy (Facility Assessment), signed 7/1/2024, revealed the Plan for average daily schedule of direct care staff to meets in 24-hour period was three (3) Registered Nurses (RNs), seven (7) Licensed Practical Nurses (LPNs), and 17 Certified Nurse Aides (CNAs). The assessment did not indicate specific staffing needs for each shift, based on changes to its resident population. Further review revealed the Facility Assessment did not include any information or plans regarding staff recruitment and retention, and did not include contingency plans for events that do not require the emergency operations plan to be activated.
On 1/16/2025 at 5:01 PM, during an interview with the Administrator, he confirmed the Facility Assessment did not break down the facility's needs regarding staffing based on the different shifts, time of day, needs of the residents. He also confirmed it did not address a plan for recruitment and retention of staff or address contingency plans for events that do not require activation of emergency operations. He stated that he completed a form or template every year and had completed this one in July 2024 prior to the revision of the regulations that occurred in August of 2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene when a Licensed Practical Nurse (LPN) did not wash her hands or change her...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene when a Licensed Practical Nurse (LPN) did not wash her hands or change her gloves during Percutaneous Endoscopic Gastrostomy (PEG) care for one (1) of (1) resident reviewed for care. Resident #22.
Findings included:
A review of the facility's policy titled Wound Care undated, revealed, .Steps in the Procedure .Wash and dry your hands thoroughly . Loosen tape and remove dressing. Discard soiled dressing and gloves into appropriate receptacles. Wash and dry your hands thoroughly. Put on gloves .
On 01/15/2025 at 3:46 PM, during an observation of PEG site care and interview with LPN #2 revealed LPN #2 did not change gloves throughout the procedure. LPN #2 used the same gloves to remove the soiled dressing, cleanse the site, and pat the site dry. LPN #2 confirmed that she did not change gloves during the procedure and acknowledged that gloves should have been changed between removing the soiled dressing and cleaning the site.
On 01/16/2025 at 9:55 AM, during an interview, Registered Nurse (RN) #1, the Infection Preventionist (IP), stated that LPN #2 should have changed her gloves multiple times during the procedure. RN #1 explained that gloves should be changed when removing the old dressing, before cleaning the site, and prior to applying a new dressing to reduce the risk of cross-contamination and infection at the PEG tube site.
On 01/16/2025 at 10:15 AM, during an interview, the Assistant Director of Nursing (ADON), RN #2, confirmed that gloves should have been changed between removing the old dressing and cleansing the site. RN #2 stated that failure to change gloves could lead to touching a clean site with contaminated gloves, increasing the risk of infection.
A record review of the admission Record revealed the facility admitted Resident #22 on 05/30/2024 with current diagnoses including Gastrostomy Status.
A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/2024 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident's cognition was moderately impaired. Further review of the documentation in Section K revealed Resident #22 had a feeding tube (PEG).
A record review of the Order Summary Report with active orders as of 1/16/2025, revealed Resident #22 had a physician's order, dated 6/26/24, to clean the PEG site daily.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on record review, interview, and facility policy review, the facility failed to ensure advance directives were completed and readily available on the charts for seven (7) of twenty-three (23) re...
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Based on record review, interview, and facility policy review, the facility failed to ensure advance directives were completed and readily available on the charts for seven (7) of twenty-three (23) residents reviewed for advance directives. (Residents #1, 28, 29, 30, 31, 34, and 43)
Findings included:
A review of the facility policy titled Advance Directives, undated, revealed, Policy Statement: Advance directives will be represented in accordance with state law and facility policy. Policy Interpretation and Implementation . 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .
A record review of the medical records for Residents #1, 28, 29, 30, 31, 34, and 43 revealed there was no documentation regarding information as to whether or not the resident had executed an advance directive.
A record review of the admission Record revealed the facility admitted Resident #1 on 01/15/1996 with diagnoses including Hemiplegia and Hemiparesis, Resident #28 on 07/09/2019 with diagnoses including Parkinson's Disease, Resident #29 on 11/21/2014 with diagnoses including Hemiplegia and Hemiparesis, Resident #30 on 03/23/2015 with diagnoses including Hemiplegia, Resident #31 on 05/14/2015 with diagnoses including Hypertension, Resident #34 on 01/06/2016 with diagnoses including Hemiplegia and Hemiparesis, and Resident #43 on 09/03/2021 with diagnoses including Hypertension.
On 01/15/2025 at 12:15 PM, during an interview, the Admissions Director revealed that many of the residents who had been in the facility for a significant amount of time did not have written documentation of their decision to formulate or not formulate an advance directive readily available in their charts. She stated that this documentation was likely in their admission files, which were currently stored in the facility's storage area.
On 01/15/2025 at 4:23 PM, during an interview, the Administrator confirmed that advance directives were not readily available in residents' charts. He stated this might be a training issue regarding the execution of all aspects of the advance directive requirements.
Aug 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record reviews and facility policy review the facility failed to implement the comprehensive care plan related to a resident's food preferences for one (1) of 19 samp...
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Based on observation, interviews, record reviews and facility policy review the facility failed to implement the comprehensive care plan related to a resident's food preferences for one (1) of 19 sampled residents. Resident #12
Findings include:
A record review of the facility's policy Using the Care Plan, undated, revealed. 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 . Policy Interpretation and Implementation .6. Documentation must be consistent with the resident's care plan .
Record review of the Face Sheet revealed the facility admitted Resident #12 on 05/01/2018 and he had diagnoses including Hypokalemia, Chronic Ischemic Heart Disease, and Dysphagia.
Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/23 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.
Record review of the Care Plan for Resident #12 revealed a Problem/Need of At risk for nutritional deficit . with a Problem Onset of 6/15/20 and an Approach to Honor food preferences.
On 08/14/23 at 12:00 PM, during an observation and interview, Resident #12 was observed eating lunch in his room. He stated that he received a pork chop on his meal tray, but he did not eat pork. He explained that a Certified Nurse Aide (CNA) had taken the pork chop off his plate and had thrown it in the garbage. An observation revealed there was a porkchop in the trash can. An observation of the meal tray card for Resident #12 revealed pork was listed as a Dislike. Resident #12 commented that there is only so much chicken strips he can eat and he did not like burgers or spicy foods.
On 08/17/23 at 10:00 AM, during an interview with Dietary #2, she explained she got the dietary likes and dislikes of all new admissions for the admission assessment. She explained Resident #12 had changed his mind several times on his likes and dislikes. Dietary #3 reviewed Resident #12's meal tray card and confirmed that pork is listed as a dislike. She stated that because the resident got a pork chop on his lunch meal tray on 8/14/23, his food preferences were not honored, and the care plan was not followed.
On 08/17/23 at 10:20 AM, during an interview with the Administrator, he explained that he expected the facility staff to follow residents' plan of care related to food preferences.
On 08/17/23 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained she expected all staff to follow the resident's care plan.
On 08/17/23 at 04:55 PM, during an interview with Registered Nurse (RN) #2, she explained that she expected all staff to follow care plans to meet resident needs and if a resident requested something different, the care plan would be updated to ensure resident choices were honored.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and facility statement review, the facility failed to ensure an enteral feedin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and facility statement review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for one (1) of two (2) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. Resident # 43.
Findings include:
The facility provided a written statement on letterhead and signed by the Director of Nurses (DON), that the facility does not have a policy that states which discipline can turn a feeding pump on or off.
On 8/14/23 at 10:54 AM, Certified Nursing Assistant (CNA) #1 was observed placing Resident #43's enteral feeding pump on hold. The CNA then repositioned the resident by turning her from her right side to her left side. After the resident's care was completed, CNA #1 turned Resident #43's enteral feeding pump back on.
On 8/14/23 at 11:00 AM, in an interview with CNA #1, she confirmed that she had put Resident #43's feeding pump on pause, but stated she is allowed to pause and restart the pump, but she is not allowed to turn the pump off.
On 08/15/23 at 1:28 PM, during an interview with Licensed Practical Nurse (LPN) #2, she confirmed that only nurses should turn the feeding pump on, off or pause. She stated it is outside of the scope of practice for a CNA a to operate the pump, such as turning it on, off or pausing it.
On 8/15/23 at 1:45 PM, in an interview with the Director of Nursing (DON), she confirmed CNAs are not allowed to operate the feeding pump in any capacity. The DON stated the CNA touching the feeding pump is outside her scope of practice. She also revealed the CNAs should have a nurse come in to assist with the feeding pump when turning the Resident.
Record review of the Face Sheet of Resident #43 revealed the facility admitted the resident to the facility on [DATE]. The resident's current diagnoses included Parkinson's disease, Dysphasia, and Contractures of Muscle, Multiple Sites.
Record review of Physician Orders, for the month of August, 2023 revealed an order for Isosource 1.5 calories @ 65 ML/HR (milliliters per hour) times 22 hours (hold time two hours for gut rest from 8:00 -10:00 AM).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
Based observation, interviews, record review, and facility policy review the facility failed to support the nutritional well-being for a resident while respecting an individual's right to make choices...
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Based observation, interviews, record review, and facility policy review the facility failed to support the nutritional well-being for a resident while respecting an individual's right to make choices about his or her diet for one (1) of 19 residents sampled. Resident #12
Findings include:
A record review of the facility's policy Food and Nutrition Services, revised October 2017, revealed .Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Policy Interpretation and Implementation 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes, and eating habits . 4. Reasonable efforts will be made to accommodate resident choices and preferences .
A record review of the facility's policy Substitutions, revised April 2007, revealed . Food substitutions will be made as appropriate or necessary . Policy Interpretation and Implementation .3. Residents' likes and dislikes will be considered when making substitutions .
On 08/14/23 at 10:38 AM, during an interview with Resident #12, he explained that he had family to bring food into the facility because the food was not good, and the kitchen brought him foods that he did not like. He reported that the dietician came around and asked him questions including his likes and dislikes, but the kitchen continued to bring food he did not like.
On 08/14/23 at 12:00 PM, during an observation and interview, Resident #12 was observed eating lunch in his room. He stated that he received a pork chop on his meal tray, but he did not eat pork. He explained that a Certified Nurse Aide (CNA) had taken the pork chop off his plate and had thrown it in the garbage. An observation revealed there was a pork chop in the trash can. An observation of the meal tray card for Resident #12 revealed pork was listed as a Dislike. Resident #12 commented that there is only so much chicken strips he can eat and he did not like burgers or spicy foods.
On 08/17/23 at 09:35 AM, during an interview with CNA #3, he explained Resident #12 was very specific on what he wanted to eat and that he did not eat pork. He confirmed that on 08/14/23, Resident #12 received a pork chop on his lunch tray. CNA #3 said he asked the resident if he wanted him to just take it off the plate, and the resident did so he just threw it away in the garbage. CNA #3 was unable to recall if Resident #12 had asked for anything else.
On 08/17/23 at 09:45 AM, during an interview with Dietary #1, he explained he was unable to remember what Resident #12 had asked for at lunch on 08/14/23. Dietary #1 explained that he sees all the residents and writes down their requests, but he does not keep it past the day. He stated that he does not know all of Resident #12's likes and dislikes, but they should be listed on his meal tray card.
On 08/17/23 at 10:00 AM, during an interview with Dietary #2, she explained she got the dietary likes and dislikes of all new admissions for the admission assessment. She explained Resident #12 had changed his mind several times on his likes and dislikes. Dietary #2 reviewed Resident #12's meal tray card and confirmed that pork is listed as a dislike. She stated that because the resident got a pork chop on his lunch meal tray on 8/14/23, his food preferences were not honored, and the care plan was not followed.
On 08/17/23 at 10:20 AM, during an interview with the Administrator, he explained he expected the kitchen and dietary staff to honor a resident's likes and dislikes of food and choices.
On 08/17/23 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained she expected the staff to offer to replace a food item if a resident asked for it to be thrown away. She stated that all staff should respect and honor a resident's likes and dislikes of food and choices and should notify the kitchen staff and management if any problems occur.
Record review of the Face Sheet revealed the facility admitted Resident #12 on 05/01/2018 and he had diagnoses including Hypokalemia, Chronic Ischemic Heart Disease, and Dysphagia.
Record review of the meal tray card for Dinner Wednesday 08/16/23 for Resident #12 revealed Pork was listed under the Dislikes column.
Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/23 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.
Feb 2020
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and facility policy review, the facility failed to make prompt efforts to resolve a resident's grievance for one (1) of 21 residents reviewed, Resident #33.
F...
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Based on staff interview, record review, and facility policy review, the facility failed to make prompt efforts to resolve a resident's grievance for one (1) of 21 residents reviewed, Resident #33.
Findings include:
A review of the facility's Filing Grievances/Complaints policy, dated 2001, revealed the facility would help residents, their representatives, other interested family members or resident advocates file grievances or complaints when such requests are made. The policy revealed, the Administrator has delegated the responsibility of grievance and/or complaint investigations to Social Services. Upon receipt of a grievance and/or complaint, Social Services will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and /or complaint. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any need to be taken. The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his/her designee will make such reports orally upon completion of investigation.
On 02/03/2020 at 2:27 PM, during an interview with Resident #33, he revealed that he had $20.00 dollars missing, which was given to him in December 2019 for Christmas. Resident #33 stated he and his Resident Representative talked to the Administrator in mid January 2020. Resident #33 stated the Administrator told him that he would see if he could give the money back. Resident #33 revealed the Administrator had not gotten back with him.
During an interview, on 02/06/2020 at 10:28 AM, Resident #33 revealed that his niece was his Resident Representative (RR). Resident #33 stated he discovered the money was missing from the zipper section of his bible case, when he went to pay a deacon for some chicken he had brought to him.
On 02/06/2020 at 10:44 AM, an interview with Resident # 33's RR revealed, she had spoken to the Administrator two (2) times in reference to the Resident money missing. The RR stated, the first time she spoke with the Administrator he told her that he would have to talk to somebody about getting the money replaced. The RR stated the Administrator never got back with her. The RR revealed she and Resident #33 had a face to face meeting with the Administrator in mid January. She stated during the meeting, the Administrator stated that he would look into giving Resident #33 his money back. The RR stated she called the Administrator on 02/05/2020, and he stated that he had to talk to someone about it. The RR revealed the Administrator still had not done anything about replacing the money.
On 02/06/2020 at 11:18 AM, during an interview, the Administrator stated that he didn't know if Resident #33 actually had the money. The Administrator further stated if you give money back to one resident then everybody would say they had money missing. The Administrator stated, We can't be responsible for his money. The Administrator revealed he told Resident #33 and the RR they could put the money in a trust account. The Administrator stated he had phoned the facility's Corporate office and had not got a response. The Administrator revealed he had forgotten about it until Resident #33's RR called him on yesterday. The Administrator stated he had opened an investigation. The Administrator was asked for a copy of the investigation, but unable to present it to the surveyor.
The Administrator revealed he had given the investigation report to the Director of Nursing (DON).
During an interview, on 02/06/2020 at 11:20 AM, the DON revealed she didn't know anything about Resident #33 missing money and had not gotten any paperwork from the Administrator.
On 02/06/2020 at 11:30 AM, during an interview with the Administrator, he stated he didn't know he needed to file a grievance. The Administrator stated Resident #33's RR had told him she didn't want him to file a grievance. The Administrator revealed that they sometimes file grievances and sometimes they don't. The Administrator revealed he had not contacted the facility's Corporate office again.
On 02/06/2020 at 11:39 AM, Resident #33's RR revealed she did not tell the Administrator not to file a grievance.
On 02/06/2020 at 11:55 AM, an interview with the Licensed Social Worker (LSW) revealed, she did not know anything about Resident #33's missing money.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and facility policy review, the facility failed to revise the care plan related to falls for one (1) of 21 resident care plans reviewed, Resident #43.
Finding...
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Based on staff interview, record review, and facility policy review, the facility failed to revise the care plan related to falls for one (1) of 21 resident care plans reviewed, Resident #43.
Findings include:
Review of the facility's Care Plans-Comprehensive policy, not dated, revealed care plans are revised as information about the resident and the resident's condition changes.
Review of Resident #43's care plan related potential for falls, onset date of 10/31/2019, revealed it was not updated to reflect falls that occurred in December 2019 or any added interventions.
Review of Resident #43's Resident Incident Reports revealed falls occurred on 12/02/2019, 12/27/2019, and 12/30/2019. Interventions from these incident reports included to encourage and instruct resident to call for assistance, encourage to use wheelchair when resident is weak, which were not included on the current care plan.
During an interview, on 02/06/2020 at 11:33 AM, Licensed Practical Nurse (LPN) #1, revealed she was usually notified about residents falls in the morning meetings with staff, and then the Director of Nursing (DON) would bring the incident reports to her to sign and review. LPN #1 stated she would then add the falls and interventions to the care plan. LPN #1 confirmed the comprehensive care plan currently on the medical record did not address Resident #43's most recent falls.
On 02/06/2020 at 12:24 PM, during an interview, the DON stated it was the facility's policy to update the care plan in the computer for each fall and new intervention. The DON stated it was important to update the care plan related to each fall to possibly prevent further falls. The DON revealed the Resident #43's care plan should have been updated as per policy, and it wasn't done.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Mississippi facilities.
Concerns
- • 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (55/100). Below average facility with significant concerns.
- • 98% turnover. Very high, 50 points above average. Constant new faces learning your loved one's needs.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Community Place's CMS Rating?
CMS assigns COMMUNITY PLACE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Mississippi, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Community Place Staffed?
CMS rates COMMUNITY PLACE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 98%, which is 52 percentage points above the Mississippi average of 47%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 88%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Community Place?
State health inspectors documented 15 deficiencies at COMMUNITY PLACE during 2020 to 2025. These included: 15 with potential for harm.
Who Owns and Operates Community Place?
COMMUNITY PLACE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 56 residents (about 93% occupancy), it is a smaller facility located in BRANDON, Mississippi.
How Does Community Place Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, COMMUNITY PLACE's overall rating (3 stars) is above the state average of 2.6, staff turnover (98%) is significantly higher than the state average of 47%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Community Place?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Community Place Safe?
Based on CMS inspection data, COMMUNITY PLACE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Mississippi. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Community Place Stick Around?
Staff turnover at COMMUNITY PLACE is high. At 98%, the facility is 52 percentage points above the Mississippi average of 47%. Registered Nurse turnover is particularly concerning at 88%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Community Place Ever Fined?
COMMUNITY PLACE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Community Place on Any Federal Watch List?
COMMUNITY PLACE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.