Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holmes County Long Term Care Center - Durant during CMS and state inspections, most recent first.
Improper reheating and hot holding of food items: Several food items on the steam table were below the required 135-degree hot holding temperature, including pureed pork chops, pureed tomatoes, pureed roll, chopped pork chops, and a hamburger patty. After reheating, multiple items still did not reach 165 degrees Fahrenheit for 15 seconds, and the Dietary Manager stated food was normally reheated two or three times, while the RD confirmed items should only be reheated once before being discarded.
Infection control was not maintained when an LPN disinfected a multi-use glucometer for only a few seconds between resident blood glucose checks instead of the required two-minute wet contact time, and placed the device directly on the med cart and bedside table without a barrier. Staff also left blood-contaminated linens on the floor in a resident room after a fall with a head laceration, rather than containing them in a biohazard bag and sending them to the laundry biohazard barrel.
Unordered Seat Belt Restraint Used Without Assessment: A resident with unspecified dementia and severe cognitive impairment was observed wearing a seat belt while seated in a wheelchair. An LPN confirmed the seat belt was a restraint and stated she had never seen the resident remove it independently. Record review did not show a physician order, quarterly restraint assessments, or a care plan addressing the seat belt, and the Administrator stated she was unaware the resident was using it.
Late Discharge MDS Assessment: A resident’s discharge MDS was not completed or transmitted within the required timeframe after the resident went to the hospital. The MDS Nurse confirmed the assessment had not been completed, and the Administrator stated it was expected to be submitted within the CMS timeframe. The resident had a history of atrial fibrillation and a BIMS score of 9, indicating moderate cognitive impairment.
A resident’s MDS was not accurately coded in Section P to reflect the use of a seat belt as a physical restraint during the assessment reference period. The MDS Nurse confirmed the seat belt was used and should have been coded, and the resident had unspecified dementia with no BIMS score, indicating severe cognitive impairment.
A resident with a Level II PASRR and diagnoses of schizophrenia and major depressive disorder had escalating behavioral issues, including threats toward other residents, bullying, and cutting up a roommate's shirt, which led to an inpatient psychiatric admission. Social Services confirmed this was a significant change in status but did not submit the required status change referral to notify the state mental health authority, and the DON stated she was not familiar with the PASRR process.
Care plans were not fully developed or followed for several residents with identified needs. A resident with dementia was observed using a seat belt in a wheelchair without a care plan addressing it, and another resident with HF and moderate cognitive impairment had an active order for double portions but no dietary care plan. A cognitively intact resident with HF reported not receiving ordered pain medication, and two residents with DM had weekly nail care interventions that were not carried out, with nails observed to be excessively long and unclean.
An LPN and a treatment nurse documented medications, supplements, and diabetic nail care as completed when they had not been provided. Surveyors observed an ordered house supplement not given to a resident with hemiplegia and moderate cognitive impairment, a scopolamine patch and Juven not administered for a resident with dysphagia and a G-tube, and diabetic nail care not performed for a resident with DM2, despite being charted as completed.
Failure to Provide Needed Nail Care: The facility failed to provide required nail care for two residents who needed assistance with ADLs. One resident with DM had fingernails observed to be very long with dark debris underneath despite a weekly diabetic nail care order on the TAR, and another resident with DM and ESRD had excessively long, thick, curved toenails after reporting he had been asking staff for care without success. The DON and RN confirmed the nail care concerns and that staff had not ensured the needed care was completed.
Interrupted PEG Feeding: A resident with dysphagia and a PEG tube had a physician-ordered enteral feeding scheduled to run 22 hours daily, but it was observed not infusing with the pump off and the formula not set up. An LPN confirmed the feeding was not running and stated it should have been turned back on after the scheduled 2-hour break; the DON also confirmed it should have been infusing per the MD order.
Pain Medication Not Available or Administered as Ordered: A resident with heart failure and intact cognition reported not receiving ordered hydrocodone-acetaminophen for pain after returning from the hospital, despite requesting it daily and rating pain 8 to 10. The MAR showed an active PRN order, but the med was not on the cart, an LPN confirmed it was unavailable, and the Administrator stated the pharmacy order had been submitted but the med had not been received and no follow-up occurred.
A resident with dysphagia and a G-tube order had an active order for a scopolamine transdermal patch for increased secretions, but an LPN documented the patch as removed and applied even though it was not administered during observation. The LPN confirmed the resident had been without the medication since the prior week because it had not been reordered, and the IC nurse and DON confirmed that the nurse giving the last dose should reorder the medication.
Medication administration errors exceeded the allowed rate, with two errors out of twenty-nine opportunities. One LPN documented a Scopolamine patch as removed and applied even though it was not administered because the patch was unavailable, and another LPN gave an incorrect dose of Atrovent nasal spray by administering one spray in each nostril instead of the ordered two sprays. The DON stated nurses were expected to review the MAR, verify the medication, administer as ordered, and then document the dose.
An LPN administered an expired liquid vitamin from a medication cart after failing to verify the expiration date, and on another cart, an LPN left two insulin-filled syringes unsecured on top of the cart while walking away to administer insulin to a resident. The DON confirmed that medications should be checked for expiration before administration and that insulin and other medications should never be left unattended and unsecured.
Hot Meals Served at Unacceptable Temperatures: Two residents reported that meals were cold, and observations confirmed hot foods were served at temperatures that were not palatable. One resident received a hot dog and fries that were cold to the touch, and another meal tray had items measured at 80, 90, and 110 degrees. The DM confirmed hot foods should be served warm and noted the kitchen did not use plate warmers.
Failure to provide ordered double portions for a resident. The resident had a physician order for double portions, but staff did not deliver them as ordered, and an observed lunch tray did not include the extra portions. The RD confirmed the order and stated staff are typically told to give two trays when double portions are ordered. The resident had heart failure and a BIMS score of 10, indicating moderate cognitive impairment.
A resident with severe cognitive impairment and multiple health issues sustained a head injury due to a failure to follow the care plan requiring two-person assistance with a mechanical lift. CNA #1 attempted a transfer alone, resulting in the resident hitting their head on a door. The facility's policy was not adhered to, leading to the incident.
A resident in a long-term care facility sustained a head injury due to a CNA's failure to follow the facility's policy requiring two-person assistance for using a full body mechanical lift. The resident, who was severely cognitively impaired and dependent on the lift for transfers, hit her head on a door during an unassisted transfer, resulting in a laceration that required medical treatment.
The facility failed to maintain the dignity and privacy of three residents. One resident was observed in a wheelchair, dressed only in a brief, visible from the hallway. Another resident was found lying in bed without clothing or covers, with the door open for supervision. A third resident had a visible urinary catheter bag without a privacy cover, contrary to facility policy. These incidents highlight a lack of adherence to privacy and dignity standards for residents with cognitive impairments.
A resident with severe cognitive impairment and Acute Pulmonary Edema was unable to reach her call light, which was found behind a privacy curtain. Staff interviews confirmed the call light should have been accessible, as the resident sometimes needs assistance. The facility's policy requires call lights to be within reach.
Two residents in an LTC facility did not receive proper nail care due to failures in implementing comprehensive care plans. One resident, a diabetic with amputations, had a care plan incorrectly assigning nail care to a CNA instead of a nurse. Another resident, requiring ADL assistance, also had unmet nail care needs despite the care plan assigning this task to a CNA. Observations confirmed long, jagged nails for both residents, and staff interviews revealed discrepancies in care plan execution.
Two residents in the facility were found with long, jagged fingernails and a brown substance underneath, indicating a failure in personal hygiene care. One resident, who is diabetic and has moderate cognitive impairment, had not received proper nail care despite the facility's policy. Another resident, who is cognitively intact, also had neglected nails, with staff acknowledging the oversight. This neglect could lead to potential skin tears and infections.
The facility failed to secure chemicals and lock the shower room, posing potential hazards. An LPN found the shower room door unlocked, with a whirlpool tub full of water and accessible chemicals. The Administrator confirmed the danger and noted that the lock issue had not been reported.
A facility failed to document the administration of controlled substances accurately. A nurse did not sign out a Norco pain pill on the narcotic log immediately after administration, as required by policy. Additionally, a discrepancy was found in the Valium tablet count for another resident, with the nurse admitting to not recording the administration. The DON confirmed that narcotics should be signed out at the time of administration.
Improper reheating and hot holding of food items
Penalty
Summary
The facility failed to ensure food was reheated and held in accordance with safe food handling standards during a meal service observation. Review of the facility policy showed cooked foods were to be held at 135 degrees Fahrenheit or higher, and if below that temperature, reheated to 165 degrees Fahrenheit for 15 seconds before being returned to hot holding. During the kitchen follow-up visit, several items on the steam table did not meet the required hot holding temperature, including pureed pork chops at 120 degrees Fahrenheit, pureed tomatoes at 100 degrees Fahrenheit, pureed roll at 110 degrees Fahrenheit, chopped pork chops at 125 degrees Fahrenheit, and a hamburger patty at 125 degrees Fahrenheit. The Dietary Manager directed staff to reheat the items in the oven, but after the first reheating, the pureed roll, chopped pork chops, and hamburger patty only reached 140 degrees Fahrenheit, 140 degrees Fahrenheit, and 145 degrees Fahrenheit, respectively, and did not reach the required reheating temperature of 165 degrees Fahrenheit for 15 seconds. The pureed pork chops and pureed tomatoes were reheated again, with the pureed pork chops reaching 140 degrees Fahrenheit and the pureed tomatoes reaching 130 degrees Fahrenheit, and the pureed tomatoes were then reheated in a pot on the stove to 150 degrees Fahrenheit. During interview, the Dietary Manager stated they normally reheat food items twice, sometimes three times, while the RD confirmed food items should only be reheated one time and then discarded after one reheating.
Infection Control Failures With Glucometer Disinfection and Blood-Contaminated Linens
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program by not ensuring staff disinfected multi-use glucometers according to the manufacturer’s required two-minute wet contact time. During observation of finger-stick blood glucose checks for three residents, an LPN wiped the glucometer between resident uses for only four to five seconds and placed the device back on top of the medication cart without a barrier present. In an interview, the LPN stated she was not sure how long the glucometer should remain wet with the germicidal wipe and said she just wiped it off and reused it. The Administrator confirmed the wipe required a two-minute wet contact time and that a few seconds was not an appropriate kill time for bacteria. The facility also failed to properly contain and remove blood-contaminated soiled linens. During initial rounds, soiled linens were observed lying on the floor in a resident’s room, and the towels contained a red substance consistent with blood after the resident had fallen and been transported to the emergency department for a head laceration. A CNA stated the linens had been left by the other shift and said she would put the items in the laundry cart in the hall. An LPN confirmed the linens were contaminated with blood and should have been placed in a yellow biohazard bag and transported to the laundry biohazard barrel for processing. The DON later confirmed blood-contaminated soiled linens should not be left on the floor and should be handled in that manner by clinical staff.
Unordered Seat Belt Restraint Used Without Assessment
Penalty
Summary
The facility failed to ensure that one resident was free from the use of a physical restraint unless needed for medical treatment. Resident #35 was observed wearing a seat belt while seated in a wheelchair in the dining room, and the facility policy stated restraints are to be used only for the safety and well-being of residents and only after alternatives have been tried unsuccessfully. Record review did not show a physician order for the seat belt, did not show quarterly restraint assessments, and did not show a care plan addressing the resident’s use of the seat belt. During observation and interview, an LPN stated she had never seen the resident take off the seat belt and confirmed that the seat belt would be a restraint. When asked if he could remove it independently, the resident was unable to answer and did not attempt to remove it. The Administrator stated she was unaware the resident was using a seat belt and confirmed there was no physician order and no quarterly assessments completed. The resident had diagnoses including unspecified dementia, and the MDS indicated severe cognitive impairment with no BIMS score and Section P coded as restraints not used.
Late Discharge MDS Assessment
Penalty
Summary
The facility failed to timely complete and transmit a discharge MDS assessment for one resident, as required by CMS guidelines. Review of the facility policy titled MDS Assessment showed the facility followed the RAI process set forth by CMS protocol. Record review of the resident’s MDS with an ARD of 6/17/2026 showed Section Z0500 was not completed. An MDS Nurse interview on 7/09/2026 confirmed the resident had discharged from the facility on 06/17/26 to the hospital and later returned, and that the discharge assessment had not been completed when the resident went out to the hospital. The nurse stated she was new to the position and confirmed assessments should be completed and submitted timely for accurate resident information and payment purposes. The Administrator stated she expected the MDS assessment to be completed and submitted within the CMS-designated timeframe. The resident was admitted on 12/11/2019 with a diagnosis of unspecified atrial fibrillation, and the MDS with an ARD of 6/17/2026 showed a BIMS score of 9, indicating moderate cognitive impairment.
MDS Not Accurately Coded for Physical Restraint Use
Penalty
Summary
The facility failed to accurately code Section P of the MDS to reflect Resident #35’s use of a physical restraint during the assessment reference period. Record review showed the resident’s MDS with an ARD of 6/24/2026 did not identify the use of a seat belt as a physical restraint in Section P. During an interview on 7/09/2026 at 1:55 PM, the MDS Nurse confirmed the resident used a seat belt during the assessment reference period and acknowledged it should have been coded in Section P. Record review also showed Resident #35 was admitted with a diagnosis of unspecified dementia, and the MDS under Section C showed no BIMS score, indicating the resident was severely cognitively impaired.
Failure to Notify State Mental Health Authority After Significant Change in Status
Penalty
Summary
The facility failed to notify the State Mental Health Authority of a resident with a significant change in status after an inpatient psychiatric admission for one of four PASRR records reviewed. Resident #6 had a Level II PASRR with diagnoses of schizophrenia and major depressive disorder, and the facility policy required that any Level II resident who experiences a significant change in status be referred promptly to the state mental health or intellectual disability authority for additional resident review, including residents with increased behavioral, psychiatric, or mood-related symptoms. Record review and interviews showed that Resident #6 had escalating aggressive and behavioral issues, including threatening violence toward multiple residents, bullying residents, and cutting up another resident's shirt. The resident reported being transferred to an inpatient psychiatric facility twice since admission, with the most recent transfer occurring after cutting up a roommate's shirt with scissors to make a pillowcase. Social Services confirmed the resident's schizophrenia, the inpatient psychiatric stay, and that the behavior constituted a significant change in status, but acknowledged that no status change referral was submitted to notify the state mental health authority. The DON also confirmed the resident experienced a significant change in status and stated she did not have knowledge related to the PASRR process.
Care Plans Not Developed or Implemented for Restraint, Diet, Pain, and Nail Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents with identified needs. Resident #35, who had diagnoses including unspecified dementia and a BIMS score indicating severe cognitive impairment, was observed wearing a seat belt while seated in a wheelchair in the dining room, but the comprehensive care plan did not address seat belt use and there was no physician order for it. Resident #76, who had diagnoses including heart failure and a BIMS score indicating moderate cognitive impairment, had an active order for double portions, but the comprehensive care plan did not address the dietary intervention. The facility also failed to implement existing care plan interventions for pain management and nail care. Resident #16, who was cognitively intact and had heart failure, had an active order for Hydrocodone-Acetaminophen for pain after returning from the hospital, but the medication was not available on the medication cart and the resident stated she had not received the prescribed pain medication despite requesting it daily for one week and rating her pain as 8 to 10. The MDS Nurse confirmed the pain management care plan had not been implemented. Resident #37 and Resident #60, both with diabetes diagnoses and BIMS scores indicating cognitive intactness, had care plans calling for weekly diabetic nail care, but observations showed their fingernails and toenails were excessively long and not cleaned or cut. Resident #37’s fingernails were observed to be approximately one and one-half inches long with a dark brown substance underneath, and Resident #60’s great toenails were excessively long, curved, thick, and jagged. The MDS Nurse confirmed the nail care interventions had not been followed, and for Resident #60 noted the podiatry referral was complicated by the resident’s dialysis schedule.
False Documentation of Medications and Treatments
Penalty
Summary
The facility failed to follow standards of nursing practice for three residents during medication and treatment care observations. The facility policy stated it follows the Nurse Practice Act and Board of Nursing Scope of Practice for all standards of nursing care and documentation. Surveyors observed that staff documented medications, supplements, and treatments as completed when they had not actually been provided, and in one case a prescribed supplement was not administered during the observed medication pass. For one resident with hemiplegia and moderate cognitive impairment, an LPN completed the scheduled morning medication pass but did not administer the ordered 4-ounce house supplement. The MAR for July 2026 showed an active order for the house supplement twice daily, yet the LPN documented it as given. During interview, the LPN and DON reviewed the MAR, and the LPN questioned whether the item was the house supplement after the documentation was discussed. For another resident with dysphagia and a gastrostomy, the MAR showed orders for a scopolamine transdermal patch every 3 days and Juven twice daily. During observation, the LPN did not administer Juven and did not remove or apply the patch as ordered, but the MAR had been initialed as completed. The LPN later confirmed she had documented both as completed without providing them and stated the patch had not been reordered when it was unavailable. For a third resident with type 2 diabetes mellitus with hyperglycemia, the treatment nurse documented weekly diabetic nail care as completed on the TAR, but later acknowledged the care had not been performed. The DON and administrator confirmed nurses should not document care or medications as given when they had not been provided.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to ensure necessary nail care services were provided for two residents who required assistance with activities of daily living. Facility policy titled Nail Care Policy stated that routine nail care, including trimming and filing, would be provided on a regular schedule and between scheduled occasions as needed. The deficiency was identified through observations, interviews, and record review for Resident #37 and Resident #60, both of whom had diagnoses including diabetes and were cognitively intact based on BIMS scores of 15. Resident #37 was observed on two occasions with fingernails approximately 1.5 inches long and a dark brown/black substance underneath them, and the resident stated they needed to be cut. The DON later confirmed the nails were very long and dirty and that the resident had a physician order for weekly diabetic nail care on the TAR. Resident #60 stated he had been asking staff for toenail care but had not received it, and both big toenails were observed to be excessively long, curved, and thick, with the remaining toenails long and jagged. RN #1 stated she was not aware of the resident's need for nail care and noted the resident could have a skin concern and infection risk due to diabetes. The DON stated staff should have addressed the resident's nail care and coordinated podiatry on dialysis days.
Interrupted PEG Feeding
Penalty
Summary
Resident #21, who was admitted with diagnoses including dysphagia and encounter for attention to gastrostomy, had a physician order for enteral feeding via PEG tube to run 22 hours daily at 50 ml per hour of Two Cal to provide 2200 kcal and 92 grams of protein. Facility policy stated that physician orders were to be followed as written. On 07/08/26 at 8:30 AM, the resident’s PEG feeding was observed not infusing, with a full bottle of Two Cal still present, tubing wrapped in paper, the feeding not set up, and the pump turned off. An LPN confirmed that the feeding was not running and stated she had arrived at work around 6:30 AM and had not checked the resident’s room until the observation. She also confirmed the feeding should only have been off for two hours and should have been turned back on at 8:00 PM the prior evening. The TAR showed the feeding was initialed as turned off at 6:00 PM and turned on at 8:00 PM on 07/07/26, and the DON confirmed that the feeding should have been infusing to maintain enteral nutrition and because it was a physician’s order.
Pain Medication Not Available or Administered as Ordered
Penalty
Summary
The facility failed to ensure prescribed pain medication was administered and available as ordered for Resident #16, who had returned from the hospital with an active order for HYDROcodone-Acetaminophen 5-325 mg, one tablet by mouth every six hours as needed for pain, dated 7/2/2026. During the Resident Council Meeting, the resident stated she had not received her prescribed pain medication since returning from the hospital a week earlier and reported requesting it daily for one week, rating her pain as 8 to 10. The resident was cognitively intact with a BIMS score of 15 and had a diagnosis of heart failure. Record review showed the MAR and pain assessments documented pain scores of 0 during the period the ordered HYDROcodone-Acetaminophen was unavailable. Observation of the medication cart on 7/8/2026 revealed the medication was not available for administration. An LPN confirmed there was an active physician order on the MAR but no medication available to give. The Administrator stated the order had been submitted to the pharmacy after the resident returned from the hospital, but the medication had not been received by the facility, and no follow-up had occurred to ensure it was received.
Failure to Administer and Reorder Scopolamine Patch
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, and administering of medications for one resident. Resident #21 had an active physician’s order for Scopolamine Transdermal Patch 72 hour, to be applied one time a day every three days for increased secretions and removed per schedule. Review of the July 2026 MAR showed that on 07/05/26 and 07/08/26, an LPN initialed that the patch had been removed and applied, but during a medication administration observation on 07/08/26 at 8:24 AM, the nurse did not remove or apply the patch as ordered. During interview, the LPN confirmed that she had initialed the MAR as if the medication had been administered even though it had not been completed. She stated there was no patch available to remove and that the resident had been out of the medication since 07/02/26. The LPN also stated she thought the medication had been reordered but later found it had not been, and she reordered it during the interview. A progress note dated 07/05/26 documented, “Reorder. Patch not available,” and the IC nurse and DON both confirmed that nurses are expected to reorder medications when residents run out.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained at 5% or less, with a reported error rate of 6.90% based on two medication errors out of twenty-nine opportunities. Facility policy stated that the medication error rate should be less than 5%, and medication administration should be monitored through observations, audits, and QAPI activities. For Resident #21, the MAR showed an order for Scopolamine transdermal patch to be applied every three days and removed per schedule, but LPN #1 initialed the MAR as if the patch had been removed and applied on two dates when observation showed the nurse did not remove or apply the patch. During interview, LPN #1 confirmed she had initialed the MAR as completed even though the medication was not administered and stated the patch was not available. For Resident #23, the MAR ordered Atrovent 0.03% nasal spray, two sprays in both nostrils before meals, but during medication pass observation LPN #4 administered only one spray into each nostril. LPN #4 confirmed the dose was incorrect and stated she became nervous and made a mistake. The DON stated her expectation was that nurses review the MAR, compare the medication with the MAR, administer medications as ordered, and then document administration.
Expired Medication and Unsecured Insulin Left on Medication Carts
Penalty
Summary
The facility failed to properly secure and store medications on two medication carts, B hall and E hall, as observed during medication administration. On B hall, an LPN was observed preparing a bottle of liquid vitamin that had an expiration date of 06/26 for administration to a resident. The LPN confirmed the vitamin was expired and stated that pharmacy usually checks the med carts for expired items once a month, but this one had been missed. The LPN also confirmed she should have checked the expiration date before preparing the medication. On E hall, an LPN drew up three residents' insulin into syringes and left two of the three insulin-filled syringes unsecured on top of the medication cart while walking down the hall to the day room to administer insulin to a resident. The LPN confirmed that the insulin-filled syringes should have been stored in the locked medication cart and that it was not safe to leave medications unsecured while away from the cart. The DON confirmed that all medications should be checked for expiration before administration and that insulin and other medications should never be left unattended and unsecured while the nurse is away from the cart.
Hot Meals Served at Unacceptable Temperatures
Penalty
Summary
The facility failed to ensure hot meals were served at a palatable temperature for two residents reviewed for dining services. The facility policy titled Food Palatability Policy stated that hot foods will be served hot and that dietary leadership will routinely evaluate appearance, taste, texture, temperature, and acceptability. During an initial tour, one resident stated her meals were cold almost every meal, and her roommate stated her food was cold as well but she had not reported it to staff because she just ate it. When the resident was served a hot dog on a bun with French fries, she stated the meal was cold, the plate was not warm to the touch, and a French fry was observed cold to the touch. On another observation, lunch trays for two residents were brought to the floor in a covered metal food cart and then picked up by an aide. Both residents stated their food was cold, and one said it was lukewarm bordering on cold and the biscuit was not warm at all. When the tray temperatures were checked, the pork chop measured 80 degrees, the stewed tomatoes 90 degrees, and the mashed potatoes 110 degrees. The Dietary Manager confirmed hot foods should be served warm and palatable and stated the kitchen did not use plate warmers because none were available, which could allow food to lose heat after it was plated. One resident had diagnoses including Major Depressive Disorder, Schizophrenia, and Anxiety Disorder and was cognitively intact; the other had Allergic Rhinitis and Unspecified Dementia and was moderately cognitively impaired.
Failure to Provide Ordered Double Portions
Penalty
Summary
The facility failed to provide the necessary care and services to meet a resident's nutritional needs by not implementing a physician-ordered dietary intervention for Resident #76. Facility policy titled Large Portions stated that large portions would be served when ordered by the physician or requested by the consultant dietitian, Director of Food and Nutrition Services, or resident, and that double portions were discouraged but, if ordered, two complete trays would be delivered. Resident #76 stated he was supposed to receive double portions with meals but had not received them since admission. Review of the resident's order summary showed a regular diet with regular texture and regular liquids consistency, along with an active order for double portions. The resident confirmed during interview that he did not receive double portions on his lunch tray, and an observation of the lunch tray showed it did not include double portions. The RD confirmed the physician order for double portions and stated that staff are typically told to give two trays when there is an order for double portions. The resident was admitted with diagnoses including heart failure, and the MDS showed a BIMS score of 10, indicating moderate cognitive impairment.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to implement the care plan for a two-person assist with the use of a full body mechanical lift for all transfers of Resident #4. This resident, who was dependent on the lift due to generalized muscle weakness, lack of coordination, impaired balance, and abnormalities of gait and mobility, sustained a head injury during a transfer. The care plan specified that transfers should be conducted with the assistance of two staff members, but this protocol was not followed. On the morning of the incident, CNA #1 attempted to transfer Resident #4 from her bed to a wheelchair using the mechanical lift without the assistance of a second staff member. During the transfer, the resident swung into the side of a door, resulting in a head laceration that required medical treatment at an emergency room. The resident was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, and had multiple diagnoses, including end-stage renal disease and heart failure. Interviews with facility staff, including the Administrator and the Director of Nursing, confirmed that the care plan was not followed, leading to the resident's injury. The facility's policy required two staff members to assist with the mechanical lift, but CNA #1 proceeded alone, resulting in the accident. The facility's investigation revealed that CNA #1 had been trained on the proper use of the lift but did not adhere to the established procedures during the incident.
Failure to Follow Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to prevent an injury to a resident by not adhering to its established policies and procedures for using a full body mechanical lift. A Certified Nursing Assistant (CNA) used the lift without the required assistance of a second staff member, which resulted in the resident sustaining a head injury. The incident occurred when the CNA attempted to transfer the resident from her bed to a wheelchair alone, causing the resident to hit her head on a door, leading to a laceration that required medical attention. The resident involved in the incident was dependent on a full body mechanical lift for all transfers and had a medical history that included inflammatory polyps of the colon, end-stage renal disease, type 2 diabetes, heart failure, and cognitive communication deficit. At the time of the incident, the resident was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. The resident was sent to the emergency room for treatment, where the laceration was closed with staples. Interviews with facility staff revealed that the CNA did not request assistance from other staff members, despite being trained and in-serviced on the requirement for two-person assistance with mechanical lifts. The CNA's written statement was inconsistent with those of other staff members, and it was confirmed that the CNA acted alone during the transfer, leading to the resident's injury.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of its residents, as evidenced by several observations and interviews. Resident #5 was observed sitting in a wheelchair, dressed only in a brief, with the room door open, making him visible from the hallway. Despite attempts to close the door, the resident, who is severely cognitively impaired, would reopen it. The resident's representative confirmed that the resident would not have wanted to be seen in such a state if he were cognizant. Resident #55 was observed lying in bed without clothing or bed covers, with the door open for supervision due to his history of falls. The resident, who is also severely cognitively impaired, frequently removed any clothing or covers placed on him. The staff acknowledged this as a privacy issue, and the resident's representative expressed concern about his exposure, despite requesting the door remain open for safety reasons. Resident #228 was observed with a urinary catheter bag visible from the hallway, without a privacy cover, which is against the facility's policy. The resident, who has moderate cognitive impairment, was admitted with chronic kidney disease. The RN Nurse Supervisor confirmed that the catheter bag should have been covered to maintain the resident's dignity, highlighting a failure to adhere to the facility's policy on maintaining privacy and dignity for residents with urinary drainage bags.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a violation of their policy. During an observation and interview, it was noted that a resident, who was receiving oxygen via nasal cannula, attempted to go to the bathroom without assistance because she could not locate her call light. The call light was found out of reach, behind a privacy curtain on her roommate's side of the room. Interviews with staff, including an LPN and CNAs, confirmed that the call light should have been within the resident's reach, as she sometimes requires assistance to move. The resident involved was admitted with a diagnosis of Acute Pulmonary Edema and was assessed as severely cognitively impaired, requiring partial assistance for activities. The facility's policy mandates that call lights be within easy reach for residents, especially those who need help. The administrator acknowledged that all residents' call lights should be accessible at all times to ensure they can request help when needed.
Failure to Implement Comprehensive Care Plans for Nail Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their nail care. Resident #63, who has a history of Type 2 Diabetes Mellitus and bilateral below-knee amputation, was observed with long, jagged fingernails and a brown substance underneath them. Despite the care plan indicating that a CNA was responsible for nail care, the RN Supervisor confirmed that nurses should handle nail care for diabetic residents. The MDS nurse acknowledged that the care plan did not accurately reflect the need for nurses to perform the nail care, and the DON confirmed the care plan was not developed accurately. Similarly, Resident #65, who requires assistance with ADLs due to impaired balance and weakness, was found with long, jagged fingernails. The care plan indicated that a CNA should perform nail care, but this was not followed. The MDS Coordinator confirmed the care plan was not adhered to, and the DON stated that CNAs were responsible for the nail care since the resident was not diabetic. The failure to follow the care plans resulted in both residents having unmet nail care needs.
Neglect in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for two residents, as evidenced by observations of long, jagged fingernails with a brown substance underneath. Resident #63, who has a moderate cognitive impairment and is diabetic, was observed multiple times with untrimmed and dirty nails. Despite the facility's policy that nurses are responsible for nail care for diabetic residents, both a CNA and an RN Supervisor confirmed the resident's nails were neglected, which could lead to potential skin tears and infections. Similarly, Resident #65, who is cognitively intact and requires assistance with personal care, was also observed with long, jagged fingernails. The CNA assigned to this resident acknowledged the need for nail trimming, and the RN Supervisor confirmed the neglect, noting the risk of self-inflicted scratches. The facility's policy mandates regular nail care, but this was not adhered to, resulting in the deficiency observed by surveyors.
Failure to Secure Chemicals and Lock Shower Room
Penalty
Summary
The facility failed to prevent potential accidents and hazards by not properly securing and storing chemicals in the whirlpool room. During an observation and interview, it was found that the shower room on the B-Hall had a coded lock on the door, but it was not functioning properly, allowing access without using the keyed lock. Inside the shower room, a whirlpool tub was full of water with soap suds, and an unlocked storage bin contained a can of bug spray, a spray bottle of bleach cleaner, and two large bottles of disinfectant. A Licensed Practical Nurse (LPN) confirmed that the door should be locked to prevent resident access to these chemicals. The Administrator confirmed that the shower room should always be locked and acknowledged the danger posed by the unlocked door and accessible chemicals. It was revealed that no one had reported the malfunctioning lock, indicating a lapse in communication and maintenance protocols.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances during medication administration. During a medication pass, a registered nurse administered a Norco pain pill to a resident but did not immediately sign it out on the narcotic administration log, as required by the facility's policy. The nurse admitted to not having the narcotic logbook with her and confirmed that narcotics should be signed out at the time of administration to maintain accurate counts and accountability. Additionally, during a narcotic log reconciliation, a discrepancy was found in the count of Valium tablets for another resident. The registered nurse acknowledged administering the medication but failed to record it on the narcotic administration log. The Director of Nursing stated that the expectation was for narcotics to be signed out at the point of administration and that nurses had been trained to keep the narcotic book with them on the medication carts.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Durant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lexington Manor Senior Care, Llc | 10.6 mi | ★★★★★ | 0 | 0 |
| Attala County Nursing Center | 15.6 mi | ★★★★★ | 0 | 0 |
| Vaiden Community Living Center | 17.4 mi | ★★★★★ | 7 | 0 |
| Middleton Oaks Health And Rehabilitation | 28 mi | ★★★★★ | 2 | 0 |
| Carthage Senior Care | 31 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.