SARDIS COMMUNITY NH
For profit - Limited Liability company
60 Beds
THE BEEBE FAMILY
Data: November 2025
Trust Grade
55/100
#139 of 200 in MS
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Sardis Community Nursing Home has received a Trust Grade of C, indicating it is average and in the middle of the pack among nursing homes. It ranks #139 out of 200 facilities in Mississippi, placing it in the bottom half of the state, and #2 out of 2 in Panola County, meaning there is only one other local option that is slightly better. The facility is experiencing a worsening trend, with issues increasing from 4 in 2024 to 7 in 2025. Staffing is a mixed bag, rated 3 out of 5 stars with a turnover rate of 40%, which is below the state average but still raises concerns about staff consistency. Notably, there are no fines on record, which is a positive aspect, although RN coverage is lacking, being lower than 88% of state facilities. Recent inspections identified several concerning incidents: one resident was not given proper assistance with bathing, resulting in a foul odor and lack of hygiene; another resident's anticoagulant care plan was not developed as required, potentially putting their health at risk; and a resident's room was in disrepair, missing paint and not reflecting a homelike environment, as they expressed dissatisfaction with the condition. While the nursing home has some strengths, such as no fines and below-average staff turnover, the deficiencies in care planning and maintaining a comfortable environment are significant weaknesses to consider.
- Trust Score
- C
- In Mississippi
- #139/200
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near Mississippi's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Mississippi facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Mississippi. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 16 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Bottom 31%
No red flags
4 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Mississippi average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Mississippi average (2.6)
Below average - review inspection findings carefully
Staff Turnover: 40%
Near Mississippi avg (46%)
Typical for the industry
Chain: THE BEEBE FAMILY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 16 deficiencies on record
Jul 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide a homelike environment for one (1) of 55 residents residing in the facilit...
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Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide a homelike environment for one (1) of 55 residents residing in the facility. Resident #40.
Findings include:
Review of the facility policy titled, Resident Environment, dated 9/15 with no revision date revealed, It is the policy of this facility to provide a safe, clean, comfortable and homelike environment .
During an observation on 6/29/25 at 4:00 PM, it was noted that Resident #40's room had an approximate two feet by four feet area of paint missing from the wall across from the bathroom door. The resident expressed concern, stating, It's been that way since I moved in here. Sometimes my family comes to visit me. I wouldn't have my home looking like that.
During an observation and interview with the Maintenance Director on 6/30/25 at 12:52 PM confirmed that he was aware of the missing paint and stated, I just haven't got around to it. He further remarked, I wouldn't want my house to look like that, and this is their home and that they are supposed to be provided with a homelike environment.
During an interview with the Administrator on 6/30/25 at 12:54 PM, she acknowledged the facility's responsibility to maintain a homelike environment and admitted to failing to notice the issue during her rounds.
Record review of the admission Record revealed that the facility admitted Resident #40 on 5/6/22.
Record review of the quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 5/14/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating that the resident had moderate cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to accurately code an admission Minimum Data Set (MDS) assessment for one (1) of 18 resident MDS...
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Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to accurately code an admission Minimum Data Set (MDS) assessment for one (1) of 18 resident MDS assessments reviewed. Resident #52
Findings include:
Review of facility policy titled, Resident Assessment, last revised on 9/19, revealed, .The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan .healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed .
Record review of Resident #52's admission MDS, section P, with an Assessment Reference Date (ARD) of 4/29/25, revealed that the bed rails were coded as a restraint.
Record review of Resident #52's Care Plan titled, Resident's Current Safety Devices and Special Equipment dated 4/22/25 revealed, .Side Rails x (times) two (2) .for bed mobility .
An observation of Resident #52's bed on 6/29/25 at 5:04 PM revealed that half side rails were attached.
During an interview on 6/30/25 at 9:55 AM with the MDS Coordinator, she acknowledged that Resident #52's bedrails were incorrectly coded, stating the bed rails were used for positioning rather than as a restraint.
During an interview with the Director of Nursing (DON) on 7/01/25 at 12:10 PM, she expressed her expectation that MDS assessments accurately reflect the resident's condition and concurred that the bed rails should not have been coded as restraints, emphasizing that they were intended to assist with positioning. She firmly stated, We do not have restraints in this building.
Record review of the admission Record revealed that the facility admitted Resident #52 on 4/22/25 with medical diagnoses that included Traumatic Hemorrhage of Left Cerebrum with Loss of Consciousness Status Unknown.
Record review of the admission MDS with an ARD of 4/29/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating that the resident had severe cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on staff interviews, record reviews, and facility policy review, the facility failed to monitor the adverse effects of an anticoagulant medication for one (1) of five (5) residents reviewed for ...
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Based on staff interviews, record reviews, and facility policy review, the facility failed to monitor the adverse effects of an anticoagulant medication for one (1) of five (5) residents reviewed for unnecessary medications. Resident #32.
Findings include:
Review of facility policy titled, Drug Administration and Documentation with last review date 3/25, revealed, .Residents shall be observed for adverse effects such as side effects, interactions, and allergic reactions. The physician shall be notified of any adverse effects that occur .
Record review of Resident #32's Physician's Orders revealed an order with a start date of 4/7/25 for Apixaban Oral Tablet 5 milligrams (mg); Give 1 tablet by mouth two times a day related to Acute Embolism and Thrombosis of Unspecified Femoral Vein.
Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #32 for June 2025, it was noted that there was no monitoring protocol in place for the side effects associated with an anticoagulant therapy.
During an interview with Licensed Practical Nurse (LPN) #2 on 6/30/25 at 10:12 AM, she revealed there were no specific orders in place for monitoring the risk for bleeding related to the anticoagulant medication. The LPN emphasized the need for monitoring to detect active bleeding and/or excessive bruising, highlighting the potential for severe complications, such as hospitalization due to bleeding or low hemoglobin (Hgb) and hematocrit (Hct) levels.
During an interview on 6/30/25 at 11:00 AM with the Minimum Data Set (MDS) Coordinator, she confirmed that monitoring for the risk of bleeding associated with anticoagulant therapy was absent. She stressed the importance of implementing monitoring tasks concurrently with the initiation of the anticoagulant order to ensure effective oversight. The MDS Coordinator expressed serious concerns, stating that without proper monitoring, the resident could die if active bleeding occurred and went unnoticed due to the lack of established protocols.
The Director of Nursing (DON) during an interview on 7/01/25 at 12:04 PM, revealed that monitoring for bleeding should commence whenever an anticoagulant is prescribed for a resident. She underscored the potential consequences of failing to implement such a monitoring plan, indicating that undetected bleeding could lead to significant health risks and possible hospitalization.
Record review of the admission Record revealed the facility admitted Resident #32 on 3/31/25 with medical diagnoses that included Acute Embolism and Thrombosis of Unspecified Femoral Vein.
Record review of the quarterly MDS with an Assessment Reference Date (ARD) of 4/16/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on staff interviews, record review, and facility policy review, the facility failed to document wound treatments for a resident with a Stage 3 pressure ulcer for one (1) of three (3) residents w...
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Based on staff interviews, record review, and facility policy review, the facility failed to document wound treatments for a resident with a Stage 3 pressure ulcer for one (1) of three (3) residents with wounds reviewed. Resident #36
Findings include:
Record review of facility policy titled, Physician Orders with a revision date of 01/25, revealed, It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner. Licensed nurses are responsible for following physician orders.
Record review of Electronic Treatment Administration Record (ETAR) for April 2025 and May 2025 revealed an order with a start date of 4/15/25 and a discontinue date (D/C) date of 5/9/25 to Clean pressure ulcer stage 2 to sacral with wound cleanser. Pat day. Apply mupirocin and collagen to wound and cover with foam dressing daily until healed. Treatments for 4/19/25, 4/21/25, 4/27/25, 5/2/25, and 5/9/25 were not documented as administered.
Record review of ETAR for May 2025 revealed an order with a start date of 5/10/25 and a D/C date of 5/23/25 to Cleanse with wound cleanser and apply Dakins wet to dry x 2 weeks and then rephotograph one time a day for treatment. Treatments for 5/18/25, 5/21/25, and 5/22/25 were not documented as administered.
Record review of ETAR for May 2025 and June 2025 revealed an order with a start date of 5/24/25 and a D/C date of 6/5/25 to Clean wound to sacral area with wound cleanser. Pat dry. Apply mupirocin and alginate to wound and cover with bordered dressing every day until healed. Treatments for 5/25/25, 5/29/25, 6/2/25, and 6/4/25 were not documented as administered.
Record review of ETAR for June 2025 revealed an order with a start date of 6/6/25 and a D/C date of 6/10/25 to Clean wound to sacral area with normal saline, pat dry, apply mupirocin, hydrofera blue, calcium alginate and cover with foam dressing daily and PRN (as needed) when soiled until healed. Treatment for 6/8/25 was not documented as administered.
Record review of ETAR for June 2025 revealed an order with a start date of 6/11/25 to Clean Stage 3 pressure injury to sacral area with normal saline, pat dry, apply mupirocin, hydrofera blue, calcium alginate and cover with foam dressing daily and PRN when soiled until healed. Treatments for 6/21/25 and 6/22/25 were not documented as administered.
On 06/30/25 at 11:00 AM, wound treatment observation and interview with Registered Nurse (RN) #2 revealed wound management services visits weekly on Wednesdays. She revealed she started at the facility in April 2025 and Resident #36 had a little bit of breakdown and we were treating it then and now it is looking much better with pink granulation. This observation confirmed the wound had pink granulation.
During an interview and record review on 6/30/25 at 12:20 PM, the Director of Nurses (DON) confirmed that after reviewing the ETAR for Resident #36's wound treatment, there were fifteen days with missing documentation for the months of April, May, and June. She revealed that it is our expectation that all treatments are documented in the system, and if another nurse goes in to render treatment and finds a bandage with an old date, they will report it to me. She revealed I just can't imagine that my nurses wouldn't do a treatment, I think they have gotten busy and failed to document in the ETAR. She revealed that documenting care is part of the continuity of care, and treatments should be done and documented accurately.
During an interview on 6/30/25 at 4:35 PM, Licensed Practical Nurse (LPN) #3 revealed she used to be the wound treatment nurse and still helps with treatments at times. She revealed she has not seen where treatments haven't been done. She revealed that if she had noticed a wound bandage with an old date then she would have reported that to the DON. She revealed that she thinks the nurses failed to document the care that they did. She revealed that she has honestly forgot to document treatment a few times herself.
In an interview on 6/30/25 at 4:59 PM, Registered Nurse (RN) #2 revealed that she is the treatment nurse and works Monday-Friday. She revealed she is new as the treatment nurse and tries to ensure she documents in the system when she provides care. She revealed that she was not sure about the weekend nurses' documentation.
Record review of Resident #36's admission Record revealed the facility admitted the resident on 5/8/24 with diagnoses which included Chronic Kidney Disease, Stage 4, and Dementia.
Record review of Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 5/27/25 revealed that Resident #36 was rarely or never understood.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to prevent the potentia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to prevent the potential spread of infection by not ensuring staff performed proper hand hygiene during three (3) of nine (9) direct care observations. Specifically, staff failed to perform hand hygiene before and after medication administration and during wound care procedures, which poses a risk of cross-contamination and infection transmission.
Findings include:
Review of the facility policy titled, Hand Hygiene with a revised date of 1/24 revealed the following: Purpose: To cleanse hands to prevent transmission of infection or other conditions . 2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room .
Review of the facility policy titled, Dressing Change Policy and Procedure with a revised date of 3/14, revealed the following: .9. Put on disposable gloves. 11.Remove dressing. Pull gloves over dressing and discard them into appropriate plastic waste bag. 12. Perform hand hygiene. Put on disposable gloves. 13. Irrigate/cleanse the area as ordered . 16. Perform hand hygiene. Apply disposable gloves . 18. Dress the area with the prescribed dressing .
An observation on 6/30/25 at 7:35 AM revealed that Licensed Practical Nurse (LPN) #1 failed to wash her hands prior to setting up the medications from the medication cart, entered resident room [ROOM NUMBER]A and administered the medications without washing her hands. LPN #1 exited the room and failed to wash her hands or use hand sanitizer before setting up the medication for resident room [ROOM NUMBER]B. LPN #1 entered resident room [ROOM NUMBER]B and administered medications without washing her hands.
An interview on 6/30/25 at 7:50 AM, LPN #1 confirmed that she didn't wash or sanitize her hands before setting up or administering both residents' medications. She confirmed that she should have practiced hand hygiene to prevent cross-contamination and prevent infections. LPN #1 stated, I guess I need to go up front and get myself a bottle of hand sanitizer for my cart.
On 6/30/25 at 11:00 AM, an observation of wound care provided by Registered Nurse (RN) #2 revealed that RN #2 gathered her supplies, entered Resident #36's room, washed her hands, and donned gloves. RN #2 removed the soiled bandages from the sacral wound, proceeded with the wound treatment and cleaned the sacral wound with normal saline. She then patted dry with a 4x4 gauze, applied mupirocin, covered with hydrofera blue and calcium alginate, and covered the sacral wound with a clean foam dressing. This observation revealed RN #2 did not change gloves or perform hand hygiene between the dirty and clean steps of the wound care procedure.
On 6/30/25 at 11:15 AM, RN #2 confirmed that she removed Resident #36's dirty wound dressings, cleaned her wound, and then administered her wound treatment, which included a clean dressing without changing her soiled gloves, washing her hands, and applying clean gloves in between the dirty and clean wound treatment process. She revealed this could contaminate the wound and prevent healing.
During an interview on 6/30/25 at 11:30 AM, the Director of Nurses (DON) revealed we have done multiple in-services regarding hand washing. Our expectation is that while administering medications, proper hand hygiene is utilized, which is a vital part of ensuring that we possibly prevent the spread of infections.
During a subsequent interview on 6/30/25 at 12:10 PM, the DON stated, It is basic 101 nursing that when doing wound care treatment, you change out your gloves between removing your dirty dressings and cleaning and applying clean bandages. She revealed that not doing proper hand hygiene can aid in the possible spread of a wound infection, and there is no excuse for it.
Record review of Resident #36's admission Record revealed the facility admitted the resident on 5/8/24 with diagnoses including Chronic Kidney Disease, Stage 4, and Dementia.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on staff and resident interviews, record reviews and facility policy review, the facility failed to develop a comprehensive care plan for a resident taking an anticoagulant (Resident #32) and fa...
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Based on staff and resident interviews, record reviews and facility policy review, the facility failed to develop a comprehensive care plan for a resident taking an anticoagulant (Resident #32) and failed to implement an Activities of Daily Living (ADL) care plan (Resident #257) for two (2) of 26 resident's care plans reviewed.
The scope for F656 was increased to E to indicate a pattern of noncompliance due to a prior citation during the last recertification survey 7/23/24.
Findings include:
Review of the facility policy titled, Care Plan Process with review date 12/24, revealed, .the facility shall develop and implement .care plan .for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care .
Resident #32
Record review of Resident #32's Physician's Orders revealed an order with a start date of 4/7/25 for Apixaban Oral Tablet 5 milligrams (mg); Give 1 tablet by mouth two times a day related to Acute Embolism and Thrombosis of Unspecified Femoral Vein.
Record review of Resident #32's care plans revealed that a comprehensive care plan had not been developed for anticoagulant therapy.
During an interview on 6/30/25 at 11:00 AM with the Minimum Data Set (MDS) Coordinator, she confirmed that a comprehensive care plan addressing the risk for bleeding associated with anticoagulant therapy was absent. She emphasized the critical nature of this oversight, stating that a care plan should have been initiated at the same time the anticoagulant order was entered to ensure proper monitoring. The MDS Coordinator expressed serious concerns, noting that the resident could die if active bleeding occurred and went unnoticed due to the lack of monitoring protocols.
During an interview with the Director of Nursing (DON) on 7/01/25 at 12:04 PM, she reiterated her expectation that a comprehensive care plan must be developed whenever an anticoagulant is prescribed for a resident. She highlighted the potential consequences of failing to implement such a plan, indicating that a resident could experience a bleed that might go undetected, potentially leading to hospitalization or worse outcomes.
Record review of the admission Record revealed that the facility admitted Resident #32 on 3/31/25 with medical diagnoses that included Acute Embolism and Thrombosis of Unspecified Femoral Vein.
Record review of the quarterly MDS with an Assessment Reference Date (ARD) of 4/16/25 under Section C revealed, a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact.
Resident #257
An observation and interview with Resident #257 on 6/29/25 at 4:58 PM, revealed that Resident #257 had a foul odor and stated he had not had a bath or shower since his admission.
Record review of the Care Plan Report for Resident #257 revealed: The resident needs assistance with ADLs (Activities of Daily Living) Date initiated 6/27/25 .Interventions: . The resident needs partial/moderate assist to transfer with bathing/showering .
During an interview with the MDS Coordinator, on 6/30/25 at 2:45 PM, she stated, The purpose of a care plan is to make sure that staff addresses and provides the care for each resident for their specific care needs.
On 7/01/25 at 10:22 AM, the DON stated, The purpose of a care plan is to provide person-centered care.
Record review of Resident #257's admission Record revealed the facility admitted the resident on 6/16/25 with medical diagnoses that included Parkinson's Disease with Dyskinesia, with fluctuations.
Record review of Resident #257's MDS with an ARD of 6/23/25 under Section C, revealed a BIMS score of 15, indicating that Resident #257 was cognitively intact.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, interviews, record review and facility policy review, the facility failed to ensure that assistance with Activities of Daily (ADL) was provided to a resident that required assist...
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Based on observation, interviews, record review and facility policy review, the facility failed to ensure that assistance with Activities of Daily (ADL) was provided to a resident that required assistance with bathing for one (1) of 26 sampled residents. Resident #257
Findings Include:
Review of the facility's policy titled, Activities of Daily Living with a revision date of 11/24, revealed under Policy: Activities of Daily Living will be documented on a daily basis by the CNA (Certified Nursing Assistant) to reflect actual care rendered to the resident. The ADL shall become a permanent part of the residents' chart . 2. ADLS shall include, but are not limited to .bathing .
On 6/29/25 at 4:58 PM, an observation of Resident #257 revealed a foul odor. An interview with Resident #257, revealed that he had not received a bath or shower since his admission two weeks ago.
During an observation and interview on 6/30/25 at 11:00 AM, the resident was observed wearing the same pants as the day before and continued to have a foul odor. Resident #257 stated that he had not gotten a bath or shower this morning. His brother, who is also his roommate, stated that he had not seen Resident #257 get a bath or go to the shower room since his admission.
An interview with 6/30/25 at 2:00 PM with CNA #1, revealed that she helps on the hall, and that Resident #257 is scheduled to receive a bath on Mondays, Wednesdays, and Fridays. She stated, I can't remember when he had a bath or shower. She attempted to locate documentation but was unable to provide any dates.
Record review of the Kardex Follow Up Question Report 6/16/25 through 6/30/25 revealed documentation of personal hygiene, but there were no notations of a bath or shower in the record.
During an interview on 6/30/25 at 2:15 PM with Licensed Practical Nurse (LPN) #1, she stated, I don't recall when he received a bath or shower. She also stated, He has never refused care with me.
On 7/01/205, an interview with the Director of Nursing (DON), confirmed that Resident #257 should have received a bath or shower on Mondays, Wednesdays, and Fridays.
Record review of Resident #257 admission Record revealed the facility admitted Resident #257 on 6/16/2025 with diagnoses including Parkinson's Disease.
Record review of Resident #257 Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 6/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #257 is cognitively intact.
Jul 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and facility policy review, the facility failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) resident assessment to the Centers for Medic...
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Based on record review, staff interview, and facility policy review, the facility failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) resident assessment to the Centers for Medicare and Medicaid Services (CMS) for a resident who transferred to an acute care facility for one (1) of 16 MDS's reviewed. Resident # 38.
Findings Include:
Review of the facility policy titled MDS Process with a revision date of 12/20 revealed, The RAI (Resident Assessment Instrument) is the source document to be used for further MDS coding guidelines, time schedules and requirements.
Record review of the Progress Notes revealed Resident #38's was transferred to a behavioral health center on 6/25/24 and returned to the facility on 7/9/24.
Record review of Resident #38's MDS Assessments revealed a discharge tracking assessment was not completed after Resident #38 was transferred to a behavior health center.
An interview with the Director of Nursing (DON) on 7/23/2024 at 2:45 PM, confirmed the MDS discharge tracking assessment for Resident #38 was not completed, and it should have been done.
An interview with the MDS Nurse on 7/23/2024 at 3:19 PM, confirmed Resident #38 did not have a discharge tracking assessment completed following the transfer to behavioral health. She revealed the facility was in the process of changing over charting systems at the time the assessment was due, and she missed it. She confirmed this should be done for tracking purposes.
Record review of the admission Record revealed the facility admitted Resident #38 on 11/23/2021 and has diagnoses that include Senile degeneration of the brain.
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
Resident #37
Record review of Resident #37's Care Plan revealed, Problem Onset: Resident has a DX (diagnosis) of Post Traumatic Stress Disorder/Emotional Trauma. The approaches were not individualized...
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Resident #37
Record review of Resident #37's Care Plan revealed, Problem Onset: Resident has a DX (diagnosis) of Post Traumatic Stress Disorder/Emotional Trauma. The approaches were not individualized and did not address potential triggers/fears related to her history of trauma.
Record review of the facility Social Assessment for Resident #37, dated 5/1/2024 revealed, Resident #37 had not experienced a traumatic event in the past, trauma-related symptoms, nor any impact to her daily routine.
An interview with Social Services (SS) #1 on 7/23/2024 at 10:45 AM, revealed Resident #37 did have inappropriate touching behaviors and would touch residents and staff.
An interview with LPN #2 on 7/23/2024 at 2:40 PM, confirmed she was aware that Resident #37 had a diagnosis of PTSD, and revealed the resident did not like people to hug her.
An interview with the Director of Nursing (DON) on 7/23/2024 at 2:53 PM, confirmed a comprehensive resident specific care plan was not developed to include Resident #37's fears and possible triggers for re-traumatization and behavior expressions staff should be aware of. She revealed the care plan was not developed because the trauma informed care assessment was not completed.
An interview with the Minimum Data Set (MDS) Nurse on 7/23/2024 at 3:45 PM, revealed the purpose of the care plan was to know how to care for the resident. She confirmed the care plan for Resident #37 was not individualized and did not address possible triggers or resident specific approaches for PTSD.
Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a care plan for nail and oral care (Resident #31) and failed to develop an individualized resident specific comprehensive care plan that identified potential fears, triggers, and/or behavioral expressions along with interventions for a resident with Post Traumatic Stress Disorder (PTSD) (Resident #37) for two (2) of 16 care plans reviewed.
Findings Include:
Record review of the facility policy, Care Plan Process with revision date of 08/17 revealed .Step 9 .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, including culturally competent and trauma-informed as well as, these items or services that would be required but are not due to the exercise of resident rights (refusal) .The facility staff shall follow the care plan .
Record review of Resident #31's Care Plan, with no problem onset date, revealed Resident has a dx (diagnosis) of Hemiplegia/Hemiparesis to right side .Approaches .Assist resident with ADLS (Activities of Daily Living) as needed .
On 07/22/24 10:00 AM, an observation of Resident #31 revealed he was lying in bed, alert, with his mouth open and his teeth had yellow substance covering all teeth. Observation also revealed brown substance under the fingernails of his left hand.
On 07/23/24 at 9:45 AM, an observation with Licensed Practical Nurse (LPN) #1, revealed Resident #31 lying in bed with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. LPN #1 confirmed that Resident #31 had yellow buildup on his teeth and revealed this could cause tooth decay and other problems with his mouth.
On 07/23/24 at 12:30 PM, an interview with DON, revealed that the purpose of the care plan was to show the care that each resident needed so the staff knew how to meet each resident's individual needs. She agreed that the staff did not follow the care plan when they failed to provide oral and nail care for Resident #31.
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, staff interview, and facility policy review the facility failed to provide Activities of Daily Living as evidenced by failure to provide daily oral care and nail care for one (1)...
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Based on observation, staff interview, and facility policy review the facility failed to provide Activities of Daily Living as evidenced by failure to provide daily oral care and nail care for one (1) of 16 residents reviewed. (Resident #31)
Findings Included:
Record review of the facility policy, Oral Hygiene with revision date of 10/17 revealed Purpose: To clean the mouth, teeth, gums .To remove bacteria and odor . Procedure .1. Offer oral hygiene before breakfast, and at bedtime .
Record review of the facility policy, Nail Care with review date of 01/24 revealed Purpose: To promote cleanliness, safety and a neat appearance . Procedure .7. Remove any debris from under the nails with the orangewood stick .
On 07/22/24 at 10:00 AM, an observation of Resident #31 revealed he was lying in bed, alert with his mouth open and a yellow substance covering all of his teeth. An observation of his hands revealed a brown substance under the fingernails of his left hand.
On 07/23/24 at 9:45 AM, an observation with Licensed Practical Nurse (LPN) #1, revealed Resident #31 lying in his bed with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. LPN #1 confirmed that he had yellow buildup on his teeth and revealed this could cause tooth decay and other problems with his mouth. She revealed that the Certified Nursing Assistants (CNA)s were supposed to do mouth care every day and usually did this during their morning rounds while they were doing their baths. LPN #1 revealed they used mouth swabs to clean Resident #31's teeth because they were afraid of aspiration if they tried to brush his teeth. She agreed that Resident #31's mouth care had not been done. LPN #1 also confirmed the brown substance under the fingernails of Resident #31's left hand and stated, I will find some clippers and do the nails now. She revealed that they scheduled fingernails to be clipped every Sunday, but nails should be looked at every day and checked for cleanliness. LPN #1 agreed dirty fingernails could cause infection if he scratched himself and the CNAs should have taken care of this.
On 07/23/24 at 9:50 AM, an interview with Director of Nursing (DON), revealed mouth care was supposed to be completed at least once a day. She revealed the CNAs were responsible for completing mouth care and they used mouth swabs if the residents couldn't tolerate brushing their teeth. The DON confirmed personal hygiene included nail care and mouth care. She revealed that the CNAs were responsible for checking fingernails and this should be done every day. She also revealed that failure to provide nail care and oral care was unacceptable and could cause sores in the mouth, tooth decay and other problems. The DON stated, This makes me angry.
Record review of Resident #31's Face Sheet revealed an admission date of 08/08/19 and included diagnoses of Parkinson's Disease, Dysphagia following Cerebral Infarction, and Cognitive Communication Deficit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to complete a Trauma Informed Care Assessment for a resident with a diagnosis of Post...
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Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to complete a Trauma Informed Care Assessment for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 1 resident reviewed for Trauma Informed Care. Resident #37
Findings Include:
Review of the facility policy titled Social Documentation - Progress Notes with a revision date of 10/23 revealed under, Policy: Social Progress Notes should be entered into the resident's Medical Record during the observation period of each MDS (Minimum Data Set) and whenever unusual circumstances occur, or for changes in resident condition or status.
An observation and interview with Resident #37 on 7/22/2024 at 12:35 PM, revealed she was sitting in a wheelchair in her room. Resident was verbal with few words and stated, I'm fine.
Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/2024 revealed, under section I, Resident #37 has a medical diagnosis of PTSD. Also revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates the resident is cognitively intact.
An interview with Social Services #1 (SS) on 7/23/2024 at 10:45 AM, explained that social assessments were due quarterly, and Resident #37 was upcoming but had not been completed yet. SS #1 confirmed she was aware that Resident #37 had a history of traumatic events, and revealed she was notified upon starting the social services position. She revealed to her knowledge the resident was diagnosed with PTSD after she was sent for a behavioral health stay and confirmed the facility did not have a social assessment that identified she had a traumatic history.
Record review of Resident #37's Psychiatric Evaluation from the behavior health stay, dated 8/20/2022, revealed (Traumatic event) as a teen. States has bad dreams about it a lot. Also revealed under, Plan: Add Zoloft (anti-depressant) .daily for questionable PTSD symptoms.
Record review of the facility Social Assessment for Resident #37, dated 5/1/2024 revealed, Resident #37 had not experienced a traumatic event in the past nor experienced any trauma-related symptoms.
An interview with Licensed Practical Nurse (LPN) #2 on 7/23/2024 at 2:40 PM, revealed she was the nurse caring for Resident #37 today. She confirmed she was aware that the resident had a diagnosis of PTSD and revealed the resident did not like people to hug her.
An interview with the Director of Nursing (DON) on 7/23/2024 at 2:53 PM, confirmed Resident #37 did not have a trauma informed care assessment completed to address the resident's diagnosis of PTSD and revealed it should have been done to address any symptoms and possible triggers.
Record review of the admission Record revealed the facility admitted Resident #37 on 6/25/21 with medical diagnoses that included Personal history of traumatic brain injury and Unspecified convulsions. A medical diagnosis of Post-Traumatic Stress Disorder was added to the resident's diagnoses list on 8/26/2022.
Jun 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on staff interview, record review and facility policy review, the facility failed to notify the physician of the failure to obtain a medication for one (1) of 16 medications reviewed. Resident #...
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Based on staff interview, record review and facility policy review, the facility failed to notify the physician of the failure to obtain a medication for one (1) of 16 medications reviewed. Resident #18.
Findings include:
Review of the facility policy titled Drug Administration and Documentation, latest revision date 04/21, revealed, .If a dose of regularly scheduled medication is refused, held or for some reason not given for more than 2 doses in a row, notify the physician .
During medication administration observation for Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/7/23 at 7:45 AM, she revealed she was unable to give Resident #18 the Clopidogrel 75 milligram (mg) as ordered, revealing the medication had not been delivered from the pharmacy. LPN #2 stated the Plavix was ordered on 6/2/23 after the resident returned from a physician visit.
Record review of the Physician Consultation Report dated 6/2/23, revealed, Findings: Mixed disease in the RLE (right lower extremity). PAD (Peripheral Arterial Disease) and Chronic Venous Insufficiency with nonhealing ulcer of RT (right) foot . New Orders: Start Plavix Daily .
A review of the Physician's Orders for Resident #18 revealed Clopidogrel 75 mg tablet give one tablet daily at 8:00 AM with an order date of 6/2/23.
During an interview with the Director of Nursing (DON) on 6/07/23 at 8:00 AM, she revealed she was unaware Resident #18 did not have his Clopidogrel. The DON revealed the resident has poor circulation and confirmed by not receiving the Plavix as ordered placed Resident #18 at risk for further circulation concerns and possible blood clots.
In an interview with the DON and LPN #2 on 6/07/23 at 8:20 AM, LPN #2 confirmed she had not notified anyone of needing the Clopidogrel.
On 6/07/23 at 3:10 PM, during a phone interview with LPN #3 confirmed the Clopidogrel was not in the facility the 6/3/23 or 6/4/23 when she worked. She confirmed she did not notify the pharmacy or the physician. LPN #3 confirmed she should have contacted the resident's physician and the pharmacy of these concerns.
An interview with Registered Nurse (RN) #1 on 6/08/23 at 8:15 AM, confirmed if a nurse is unable to get a medication the physician needs to be notified.
During an interview with the Administrator on 6/08/23 at 8:28 AM, she revealed the nurses did not give the Clopidogrel as ordered and failed to notify the pharmacy of the medication order and did not notify the physician of not having the medication to be administered.
Record review of the admission Record revealed that the facility admitted Resident #18 to the facility on 8/03/15 with diagnoses of Atrial Fibrillation, Heart Failure, and Atherosclerotic Heart Disease of Coronary Arteries.
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, resident and family interview, staff interview, record review, and facility policy review the facility failed to ensure residents were free from restraints for one (1) of 59 resi...
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Based on observation, resident and family interview, staff interview, record review, and facility policy review the facility failed to ensure residents were free from restraints for one (1) of 59 residents reviewed. Resident #42
Findings Include:
Record Review of the facility policy titled, Restraints and Safety Devices, with a revision date of 10/22, revealed, It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints .
An observation on 6/6/23 at 9:15 AM, revealed Resident #42 was in the bed laying on a winged mattress with full siderails in the upright position on both sides of the bed.
During an interview with Resident #42 on 6/6/23 at 9:16 AM, she shook her head no when asked if she knew why she was on the winged mattress and had full siderails up on either side of the bed.
A record review of Resident #42's Physician Orders , dated June 2023 revealed that she did not have an order for a winged mattress or full side rails.
A record review of Resident #42's Nurse Data Collection and Screening, completed on 5/17/23, revealed that she did not have a bed rail or a restraint in use.
A record review of Resident #42's medical record revealed she did not have a consent or assessment for the use of the winged mattress or full siderails.
An observation of Resident #42 on 6/7/23 at 4:00 PM, revealed she was in bed laying on a winged mattress with full siderails in the upright position on both sides of the bed.
During an interview on 6/7/23 at 4:02 PM, with Resident #42's Resident Representative (RR), she stated she did not know anything about the winged mattress or full side rails and stated that Resident #42 did not like the mattress.
During an interview with Resident #42 on 6/7/23 at 4:04 PM, she shook her head no when asked if she liked the winged mattress. Resident #42 shook her head yes when asked if the mattress was uncomfortable.
During an interview with Licensed Practical Nurse (LPN) #1 on 6/7/23 at 4:20 PM, she stated that winged mattresses are used to prevent residents from falling out of bed. She stated that they only used one-half (1/2) side rails in the facility for bed mobility. She stated that if a resident had a winged mattress or full side rails, then they would not have a Physician's order for them. The order would not show up on the electronic Medication Administration Record (eMAR). She stated she would know if a resident was supposed to have a winged mattress or full side rails because she would be told in report. LPN #1 stated that she was familiar with Resident #42 and the resident did not have a winged mattress or full side rails.
During an interview with the Minimum Data Set (MDS) Nurse on 6/7/23 at 4:30 PM, she stated that if a resident had a winged mattress or full side rails, then they would have a physician's order, assessment, and care plan. She stated that Resident # 42 did not have a winged mattress, full side rails, physician's orders for a winged mattress and side rails, or a care plan for a winged mattress and side rails. She stated when she did the admission MDS she would have seen it and questioned it. The MDS Nurse stated that Resident # 42 moved rooms and if she now has a winged mattress and full side rails it is likely because that was the bed in the room when she moved into it.
During an interview on 6/7/23 at 4:42 PM, with the Director of Nursing (DON) she stated that if a resident had a winged mattress or full side rails they should have a physician's order, assessment, and care plan; and that it would show up on the eMAR for the staff to know that the resident was supposed to have it.
During an observation and interview with the DON on 6/7/23 at 4:45 PM, she verified that Resident #42 did have a winged mattress and full side rails on her bed and that she should not have them. The DON stated that these items were a restraint and if the resident attempted to get out of bed with them in place she could fall and injure herself.
During an interview with the Administrator on 6/8/23 at 8:15 AM, she verified that the side rails on Resident #42's bed were 54 inches long.
Record review of the Face Sheet revealed that the facility admitted Resident #42 to the facility on 5/10/23 with a diagnosis of Cerebral Infarction.
Record review of the MDS Section C with an Assessment Reference Date (ARD) date of 5/17/23, revealed that Resident #42 had a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated that she was moderately cognitively impaired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, and facility policy review the facility failed to assure that services were being provided according to accepted standards of clinical practice as...
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Based on observation, staff interview, record review, and facility policy review the facility failed to assure that services were being provided according to accepted standards of clinical practice as evidenced by Clopidogrel (Plavix) signed off as administered on the medication record for Resident #18 by staff on four (4) consecutive days when the medication had not been dispensed by a pharmacy for one (1) of 16 medications reviewed.
Findings include:
A review of the facility policy titled, Administration of Medications, revised 10/17, Purpose: To administer medications in accordance with best practice.
During medication administration observation for Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/7/23 at 7:45 AM, she revealed she was unable to give Resident #18 the Clopidogrel 75 milligram (mg) as ordered, revealing the medication had not been delivered from the pharmacy. LPN #2 stated the Plavix was ordered on 6/2/23 after returning from a physicians visit.
A review of the Physician's Orders for Resident #18 revealed Clopidogrel 75 mg tablet give one tablet daily at 8:00 AM with an order date of 6/2/23.
A review of the Physician Consultation Report dated 6/2/23, revealed under New Orders: Start Plavix Daily .
A review of the Electronic Medication Administration Record (e-MAR) for June 2023, revealed Clopidogrel 75 mg tablet daily at 8:00 AM was signed off as administered by LPN #3 on June 3rd and 4th and by LPN #2 on June 5th and 6th.
An interview with the Director of Nursing (DON) on 6/07/23 at 8:00 AM, she revealed she was unaware Resident #18 did not have his Clopidogrel and confirmed the Resident has poor circulation and not receiving the Clopidogrel as ordered placed Resident #18 at risk for further circulation concerns and possible blood clots.
An interview with the DON and LPN #2 on 6/07/23 at 8:20 AM, the State Agency (SA) presented the e-MAR record to LPN #2 and asked if she administered the Clopidogrel to Resident #18 on June 5th and 6th as it was signed off as administered. LPN #2 revealed to the SA and DON she did not give the Clopidogrel stating I guess I was just clicking the e-MAR. LPN #2 confirmed she should not have signed the medication as given.
A phone interview with LPN #3 on 6/07/23 at 3:10 PM, she revealed she did not administer the Clopidogrel 75 mg because she questioned where the order came from. SA questioned LPN #3 as to why the medication record had her initials as Plavix being administered. LPN #3 revealed she should not have signed the Clopidogrel as given stating I must have been clicking the computer screen to fast. LPN #3 confirmed the medication was not in the facility and she should not have signed the Clopidogrel off because it was not given.
An interview with the Minimum Data Set Nurse (MDS) on 6/07/23 at 1:30 PM, she revealed she called and spoke with a pharmacist at the pharmacy and the pharmacist revealed there was no record of an order for Clopidogrel for Resident #18 until the DON called this morning on 6/7/23.
An interview with the Administrator on 6/08/23 at 8:28 AM, she revealed the nurses did not give the Clopidogrel as ordered. The Administrator confirmed LPN #2 and LPN #3 did not follow the standards of practice for medication administration when they signed off medications as given when the medication was not delivered until 6/7/23.
Record review of the admission Record revealed that the facility admitted Resident #18 to the facility on 8/03/15 with diagnoses of Atrial Fibrillation, Heart Failure, and Atherosclerotic Heart Disease of Coronary Arteries.
Record review of the MDS with an Assessment Reference Date (ARD) of 3/16/23 with a Brief Interview of Mental Status (BIMS) score of 15 which indicates Resident #18 is cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, and facility policy review the facility failed to meet the pharmaceutical needs of a resident when staff failed to obtain and provide the medicati...
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Based on observation, staff interview, record review, and facility policy review the facility failed to meet the pharmaceutical needs of a resident when staff failed to obtain and provide the medication Clopidogrel for Resident #18 for one (1) of 16 medications reviewed.
Findings include:
A review of the facility policy titled, Physician Orders, revised 1/23, revealed It is the policy of the facility that all physician's orders will be implemented timely and carried out in a professional manner . An order for medication or supplies shall be placed to the pharmacy or appropriate supplier.
A medication administration observation for Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/7/23 at 7:45 AM, revealed she was unable to give Resident #18 the Clopidogrel 75 milligram (mg) as ordered. She revealed the medication had not been delivered from the pharmacy. LPN #2 stated the Clopidogrel was ordered on 6/2/23 after the resident returned from an outside appointment. She confirmed she faxed the order to the pharmacy that day. LPN #2 also revealed when she came back to work on Monday 6/5/23 the medication was not in the facility, so she notified pharmacy again on 6/5/23 and 6/6/23 and the physician of not having the medication to administer.
A review of the Physician's Orders for Resident #18, revealed Clopidogrel 75 mg tablet give one tablet daily at 8:00 AM with an order date of 6/2/23.
A review of the Physician Consultation Report dated 6/2/23, revealed under New Orders: Start Plavix Daily .
During an interview with the Director of Nursing (DON) on 6/07/23 at 8:00 AM, she revealed she was unaware Resident #18 did not have his Clopidogrel. A review of the emergency drug kit with the DON revealed there is no Clopidogrel on the formulary list. The DON placed a call to pharmacy to have the medication sent from back-up pharmacy. The DON revealed the resident has poor circulation and confirmed by not receiving the Plavix as ordered placed Resident #18 at risk for further circulation concerns and possible blood clots.
In an interview with the DON and LPN #2 on 6/07/23 at 8:20 AM, revealed the DON asked LPN #2 Who did you report to that Resident #18 needed Clopidogrel and if you notified the pharmacy who did you speak with. LPN #2 confirmed she had not notified anyone of needing the Clopidogrel.
Record review of the Electronic Medication Administration Record (EMAR) revealed an order dated 6/2/23 Clopidogrel 75 mg tablet, oral 8a (AM) daily. Give 1 tab (tablet) by mouth daily. Documentation on the EMAR revealed staff initials were listed on 6/3/23 through 6/6/23 indicating the medication had been administered.
An interview with the Administrator on 6/07/23 at 1:20 PM, revealed LPN #2 failed to order the Clopidogrel when she obtained the order on 6/2/23.
During an interview with the Minimum Data Set Nurse (MDS) on 6/07/23 at 1:30 PM, revealed she called and spoke with a pharmacist at the pharmacy and the pharmacist revealed there was no record of an order for Clopidogrel for Resident #18 until the DON called this morning 6/7/23 at 8:02 AM.
During a phone interview with LPN #3 on 6/07/23 at 3:10 PM, confirmed the Clopidogrel was not in the facility the 6/3/23 or 6/4/23 when she worked. She confirmed she did not notify the pharmacy or the physician. LPN #3 confirmed she should have contacted the resident's provider and the pharmacy of these concerns.
An interview with Registered Nurse (RN) #1on 6/08/23 at 8:15 AM, revealed all new medication orders are faxed to the Pharmacy to be filled and delivered. She went on to say if orders are received after hours, the pharmacy has an on-call pharmacist, and they would notify a local pharmacy that contracts to delivery any medications needed immediately. RN #1 confirmed if a nurse is unable to get a medication the physician needs to be notified.
During an interview with the Administrator on 6/08/23 at 8:28 AM, she revealed the nurses did not give the Clopidogrel as ordered and failed to notify the pharmacy of the medication order and did not notify the physician of not having the medication to be administered. The Administrator confirmed the Clopidogrel was not delivered until 6/7/23 and confirmed LPN #2 and LPN #3 should have followed up with pharmacy and notified the DON they did not have the medication.
Record review of the admission Record revealed that the facility admitted Resident #18 to the facility on 8/03/15 with diagnoses of Atrial Fibrillation, Heart Failure, and Atherosclerotic Heart Disease of Coronary Arteries.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 3/16/23 revealed Resident #18 had a Brief Interview of Mental Status (BIMS) score of 15 which indicates Resident #18 is cognitively intact.
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 record review, staff interview, and facility policy review the facility failed to establish and maintain an infection prevention and control program designed to help prevent transmission of c...
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Based on record review, staff interview, and facility policy review the facility failed to establish and maintain an infection prevention and control program designed to help prevent transmission of communicable diseases and infections as evidenced by failure to administer a second step Tuberculin (TB) skin test to employees prior to working in the facility for one (1) of 10 employees reviewed.
Findings include :
Review of the facility policy titled, TB Testing MS, with a revision date of 7/19 revealed, II: Employee Testing for Tuberculosis .Baseline .Employees with a negative tuberculin skin test and a negative symptom assessment shall have the second step of the the two-step Mantoux tuberculin skin test, administered, read, and documented in the employee's personnel record within fourteen (14) days of employment.
A record review of the Maintenance Supervisor's EmployeeTuberculin TB Test Record revealed he received a step-one (1) Tuberculin purified protein derivative (PPD) skin test on 4/12/23 with a reading of 00 millimeters (mm) on 4/14/23. There is no evidence that the Maintenance Supervisor was offered or received a second step TB skin test.
During an interview with Licensed Practical Nurse (LPN) Assessment Nurse on 6/8/23 at 11:45 AM, she stated that the Maintenance Supervisor did not receive a second step TB skin test. She stated that she previously administered TB skin testing but was moved into a different position. She stated now the Director of Nursing (DON) is responsible for the TB skin testing and she tries to help her.
During an interview with the Administrator on 6/8/23 at 11:50 AM, she stated that she thought the LPN Assessment Nurse was responsible for administering the TB skin testing.
During an interview with the DON on 6/8/23 at 12:35 PM, stated that the Staff Development Coordinator (SDC) is responsible for TB skin testing. She stated that the LPN Assessment Nurse was moved out of the SDC role, so she and the LPN Assessment Nurse have both been doing the TB Skin tests. The DON confirmed that during the time the facility was looking for a SDC there was not a consistent plan in place to ensure a TB test was not missed. She stated not doing a TB skin test on a staff or resident could cause the spread TB in the facility.
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
- "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.
- • 40% turnover. Below Mississippi's 48% average. Good staff retention means consistent care.
Concerns
- • 16 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (55/100). Below average facility with significant concerns.
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 Sardis Community Nh's CMS Rating?
CMS assigns SARDIS COMMUNITY NH an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Mississippi, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Sardis Community Nh Staffed?
CMS rates SARDIS COMMUNITY NH's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the Mississippi average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sardis Community Nh?
State health inspectors documented 16 deficiencies at SARDIS COMMUNITY NH during 2023 to 2025. These included: 16 with potential for harm.
Who Owns and Operates Sardis Community Nh?
SARDIS COMMUNITY NH is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE BEEBE FAMILY, a chain that manages multiple nursing homes. With 60 certified beds and approximately 54 residents (about 90% occupancy), it is a smaller facility located in SARDIS, Mississippi.
How Does Sardis Community Nh Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, SARDIS COMMUNITY NH's overall rating (2 stars) is below the state average of 2.6, staff turnover (40%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Sardis Community Nh?
Based on this facility's data, families visiting should ask: "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?"
Is Sardis Community Nh Safe?
Based on CMS inspection data, SARDIS COMMUNITY NH 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 2-star overall rating and ranks #100 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 Sardis Community Nh Stick Around?
SARDIS COMMUNITY NH has a staff turnover rate of 40%, which is about average for Mississippi nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Sardis Community Nh Ever Fined?
SARDIS COMMUNITY NH 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 Sardis Community Nh on Any Federal Watch List?
SARDIS COMMUNITY NH 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.