Neshoba County Nursing Home

Penalty

Inspection fine: $15,945

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain a secure environment for residents identified as at risk for elopement and wandering on a locked Alzheimer’s unit. Two residents with severe cognitive impairment, both assessed with high elopement risk scores of 95, were able to exit the secured unit and the facility without appropriate staff detection or intervention. The facility’s own policy stated that residents who exhibit wandering behavior or are at risk for elopement would receive adequate supervision and care in accordance with their person-centered care plans, but this did not occur for these residents. On the day of the incident, a door alarm to the exit leading from the Alzheimer’s unit into an enclosed courtyard sounded at approximately 1:32–1:35 PM. Staff responded to the alarm, but the responding staff member did not see any residents in the courtyard and silenced the alarm. At that time, one resident had entered the door code, opened the door, and exited the unit with another resident. Staff interviews revealed that the two residents had last been seen leaving the dining area around 1:00 PM, and one CNA went on break shortly thereafter, returning a little after 1:30 PM to find the door alarm sounding. Despite the alarm and staff response, no one identified that the two at-risk residents had left the unit. Subsequently, one of the residents was observed outside on facility property at approximately 1:48 PM and was brought back inside by staff, who then discovered that the other resident was missing during a head count at approximately 1:52 PM. Interviews and the facility’s investigation showed that the missing resident had obtained or knew the door code and used it to leave the locked unit, then left the facility grounds and traveled off-site. The resident later reported that he knew the code and used it to exit because he wanted to go home, and another resident confirmed that he had opened the door and let him outside. Staff also acknowledged that door codes had been given to family and visitors in the past so they could enter and exit the unit, which contributed to the resident’s ability to obtain and use the code to leave the secured area undetected. The missing resident, who had diagnoses including cerebral infarct and schizophrenia and a BIMS score indicating severe cognitive impairment, was not located on the unit or facility property during the search. Law enforcement and the resident’s responsible party were notified, and it was determined through phone contact and law enforcement assistance that the resident had already been picked up in a vehicle and transported away from the facility. The resident was ultimately located by deputies in another county at his home address and returned to the facility later that afternoon. During this time, the resident remained unsupervised away from the facility, despite his known elopement risk and cognitive impairment, demonstrating a failure to ensure adequate supervision and secure exit controls for residents at risk for elopement. The survey agency determined that this failure to supervise and prevent elopement for residents identified as elopement and wandering risks constituted noncompliance with 42 CFR 483.25(d)(1)(2) (F689 – Free of Accident Hazards/Supervision/Devices) at a Scope and Severity level J, representing Immediate Jeopardy and Substandard Quality of Care. The Immediate Jeopardy and Substandard Quality of Care were determined to have begun on the date of the elopement event and were later classified as Past Non-Compliance based on the facility’s subsequent actions, but the deficiency itself centered on the initial failure to prevent the residents’ unsupervised exit from the secured unit and facility.

Removal Plan

• Recovered Resident #2 and returned him to the unit; placed Resident #2 on one-to-one monitoring to ensure safety.
• Performed a resident head count on the unit to account for all residents.
• Initiated Code Yellow (missing resident).
• Notified facility administration and law enforcement.
• Initiated a multi-facility property search by all departments of the nursing home and hospital.
• Obtained Resident #1’s cell phone number from the responsible party and called the resident; coordinated with law enforcement to ping the cell phone location.
• Assessed Resident #1 upon return for distress/injury and placed Resident #1 on one-to-one monitoring to ensure safety.
• Notified the Mississippi State Department of Health via hotline.
• Changed all exit door codes to the Alzheimer’s unit to secure the unit.
• Initiated Elopement and Wandering in-service with all staff; required completion before staff could work.
• Reviewed Elopement and Wandering Resident policies.
• Reviewed all Alzheimer’s Unit residents’ elopement care plans.
• Obtained and installed a doorbell on the unit to allow visitors to call for access; eliminated visitor access to unit door codes.
• Held a post-elopement event review/QA meeting to review safety measures and ongoing monitoring.
• Installed a safety alarm on the courtyard exit gate to notify staff when the gate is ajar.
• Initiated safety alarm checks every shift to ensure doors are closed and alarms function properly.
• Changed Resident #1 to every fifteen-minute checks.
• Ordered badge access for all entry/exit doors on the Alzheimer’s unit.
• Submitted a written investigation report to the Mississippi State Department of Health.
• Scheduled activity staff for increased monitoring and activities on the Alzheimer’s unit.
• Placed Resident #1 on one-to-one monitoring for increased exit-seeking behaviors.
• Installed live-view cameras with a screen at the nurses’ station for increased supervision of all entrance/exit doors to the Alzheimer’s unit.
• Ordered hallway mirrors for increased visualization of hallways and exit doors.
• Held a follow-up QA meeting to discuss the ongoing elopement plan, effectiveness, and monitoring.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure kitchen equipment and surrounding areas were maintained in a clean and sanitary condition during two of three kitchen tours. During the initial kitchen tour, the deep fryer had a thick yellow and black substance with food particles built up down the entire right side, the left side of the stove had splattered buildup, and there was a thick greasy substance with food particles underneath the fryer and extending across the surrounding floor. The facility policy required staff to maintain kitchen sanitation through a written comprehensive cleaning schedule, with tasks posted, trained on, and initialed and dated when completed. During interview and observation, the Dietary Manager confirmed fryer oil was to be changed weekly and the fryer exterior cleaned at that time, with staff required to initial and date completion. He acknowledged the fryer’s right side and the stove’s left side had buildup and stated it looked like it had not been cleaned in a while. He also confirmed the greasy buildup under and around the fryer should have been mopped and stated cleaning the floors was not currently included in the cleaning schedule, but should be. Review of the Weekly Cleaning Schedule for September 2025 showed initials indicating fryer cleaning was completed, but the Dietary Manager acknowledged the task could be initialed as done without actually being performed. A Dietary Supervisor stated cleaning the floors was everyone’s responsibility and confirmed the dirty fryer, stove, and greasy buildup were not acceptable. The Administrator stated the kitchen where resident meals are prepared is expected to always be kept clean and sanitary to prevent any potential foodborne illness.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the use of a bed alarm did not constitute a physical restraint for one resident reviewed for restraints. The resident was observed lying in bed with her hands clenched and body appearing stiff while the bed alarm sounded with only slight movement. During the observation, the resident stated, "If I misbehave, this thing beeps, I have to be still," and the alarm continued sounding despite attempts by an LPN to adjust it and then replace it with another alarm. The resident later stated that she disliked the alarm because it woke her during the night and scared her. Record review showed the resident was admitted with dementia and had a BIMS score of 03, indicating severe cognitive impairment. The facility policy stated that restraint use is limited to circumstances in which the resident has medical symptoms that warrant restraints. The Director of Clinical Services stated the bed alarm was used so staff could hear the resident try to get up and assist her to prevent falls, and also stated the bed alarm should not restrain residents or keep them from moving freely. The resident had a bed alarm assessment dated 9/03/2025 and an informed consent for use of the bed/chair alarm signed on 12/16/24.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement comprehensive care plans for multiple residents in areas identified in their assessments and care plans, including ADLs, wandering, gastrostomy tube care, and therapeutic diet. The facility policy stated that each resident’s comprehensive person-centered care plan must include measurable objectives and time frames to meet identified medical, nursing, mental, and psychosocial needs. Surveyors found that for five of 26 care plans reviewed, the documented interventions were not carried out as written. For Resident #5, the ADL care plan included assistance with personal hygiene and grooming, including facial hair removal as needed, but observations showed multiple gray chin hairs about one-half inch long on two separate occasions. Staff confirmed facial hair removal was part of bath time care and was included in the care plan. For Resident #105, the ADL care plan included weekly nail care to keep nails clean and neat, but observations showed long fingernails on both hands about one-half inch past the fingertips on two occasions, and staff confirmed the nails needed trimming. Both residents had severe cognitive impairment based on BIMS scores of 03 and diagnoses including dementia-related conditions. For Resident #57, the elopement risk plan of care directed staff to utilize a wander alert device, but observations showed the wander alert bracelet lying on a cabinet in the room rather than being worn, and RN staff confirmed it was not on the resident. For Resident #64, the feeding tube plan of care directed staff to ensure tube placement before use, but an LPN flushed the enteral tube and administered medications without first verifying placement. The resident also had long, jagged fingernails with brown substance underneath. For Resident #134, the nutritional care plan ordered a pureed diet with nectar thickened liquids, but the resident was served regular consistency Glucerna and a CNA inserted a straw into the container for him to drink; the DON confirmed the care plan was not followed. Resident #64 had anoxic brain injury and a gastrostomy tube, while Resident #134 had stroke-related diagnoses and no cognitive deficits on MDS.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide ADL care related to grooming for three sampled residents by not ensuring nail care and shaving were completed as part of personal hygiene. The facility policy stated that residents unable to perform ADLs would receive necessary services to maintain grooming and personal hygiene. Resident #5, who had diagnoses including Alzheimer's disease, unspecified dementia, and insomnia and a BIMS score of 03, was observed with multiple scattered gray chin hairs measuring about one-half inch. An LPN confirmed the facial hair should have been removed during bathing, and staff interviews stated CNAs were expected to assess and remove facial hair as part of personal hygiene. The DON also stated residents were expected to be well groomed, including facial hair removal, and the resident had signed consent for facial and bodily hair removal. Resident #64, who had anoxic brain injury and severely impaired cognitive skills, was observed lying in bed with long, jagged thumb nails with brown substance underneath, and later all fingernails were found long and dirty. The Director of Clinical Services confirmed the nails were long and dirty and stated that if nails are not kept trimmed and clean, the resident could easily get a break in the skin and develop an infection. Resident #105, who had left hemiplegia, acute brainstem stroke, dementia, and a BIMS score of 03, was observed with long fingernails on both hands extending about one-half inch past the fingertips. An LPN confirmed the nails needed trimming and stated they had not been clipped in a while, while the DON stated CNA staff were expected to check fingernails and clip them if needed and that fingernail care was to be done weekly as part of personal hygiene and grooming.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident identified as an elopement risk had the physician-ordered wander alert bracelet applied. Facility policy stated that wandering residents deemed to be a flight risk would have a code alert bracelet placed on their wrist or ankle, and staff were to check each transmitter and door each shift and document that they were functioning correctly. However, during observation, the resident was seen sitting in her recliner reading while the wander alert bracelet was lying on a bookshelf in her room, and the resident stated, "That's something somebody gave me." A later observation showed the bracelet still on the bookshelf. Record review showed the resident had a physician order for a code bracelet/wander alert TAR twice daily and to ensure the code alert was intact. RN #1 stated the resident was supposed to be wearing the bracelet because she had Alzheimer's disease and was ambulatory, and confirmed during the observation that the resident did not have the bracelet on. The DON also confirmed the resident was at risk for elopement by not wearing the wander device as ordered. The resident's record showed admission with Alzheimer's disease, and the MDS documented a BIMS score of 3, indicating severe cognitive impairment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper placement of a gastrostomy tube before medication administration for Resident #64, who was admitted on 1/23/19 with diagnoses including anoxic brain injury and received feedings through a gastrostomy tube. Facility policy titled Enteral Tube Medication stated that enteral tube placement must be checked via auscultation and/or aspiration before any fluids or medication are administered. During an observation on 9/30/25 at 12:10 PM, an LPN flushed the resident’s enteral tube with water and administered medications without first verifying tube placement. In interview, the LPN confirmed she did not check placement before giving the medications and stated it should have been done to ensure the tube was in the proper place and to prevent aspiration. The DON also confirmed that enteral tube placement should be verified prior to flushes or medication administration to ensure the tube had not migrated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safe storage and security of medications for one resident reviewed during the initial tour. During an observation and interview, Resident #101 was found lying in bed with a Symbicort inhaler and a Spiriva inhaler left on a table in the room. The resident stated the nurse had forgotten to come back and get them after administering them that morning. The facility policy stated residents are not permitted to keep medications in their room unless the interdisciplinary team has determined it is safe and the physician has ordered it. Record review showed Resident #101 had active orders for Tiotropium (Spiriva Respimat) inhalation daily and Budesonide-formoterol inhalation twice daily. RN #1 stated Resident #101 did not have an order to self-administer medications and that the nurse should remain in the room and watch the resident take the medication, with medications never left unattended. LPN #3 confirmed she left the inhalers on the TV stand after stepping next door to assist another resident. The DON stated her expectation was that all medications be securely stored in the medication carts and never left in a resident's room. Resident #101 was admitted on 8/17/20 and had diagnoses including atherosclerotic heart disease; the MDS showed a BIMS score of 13, indicating the resident was cognitively intact.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide Resident #134 with a prescribed therapeutic diet when a regular consistency creamy strawberry Glucerna was placed on his meal tray instead of the ordered nectar-thick Glucerna. During lunch meal observation, the resident had nectar-thick water and nectar-thick sweet tea, but the Glucerna on the tray was not thickened. CNA #2 opened the Glucerna and inserted a straw for the resident to drink, and confirmed it was not nectar consistency. RN #1 later confirmed the Glucerna was regular consistency and stated that not providing the prescribed nectar-thick liquids could cause the resident to choke and aspirate. She also confirmed the meal ticket indicated the resident was supposed to receive thickened Glucerna with the meal. Record review showed the resident had a diet order for a mechanical soft, nectar/mildly thick diet with Glucerna at lunch and supper, along with aspiration precautions. The resident had diagnoses including right thalamic infarction, stroke, and communication impairment, and his MDS showed a BIMS score of 15 with no cognitive deficits. The DON, Dietary Manager, and Dietary Supervisor all confirmed the Glucerna should have been thickened by the kitchen and that staff on the serving line were responsible for checking meal tickets against what was served. The Dietary Supervisor stated she missed the error that day.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper infection prevention and control for respiratory equipment when Resident #53’s nebulizer mouthpiece was observed sitting on top of the resident’s oxygen concentrator with the mouthpiece uncovered and not stored in a clean or protected manner. The resident had an order for Ipratropium-Albuterol 3 mL inhalation solution twice daily as needed for wheezing and was admitted with a diagnosis of airway-centered interstitial fibrosis. The facility policy for nebulizer therapy stated that treatments are to be administered using proper technique and standard precautions. During observation and interview, the Clinical Services Director confirmed the mouthpiece was not stored properly and stated it should be covered and stored in a clean bag or container because leaving it out could cause an infection. The DON also confirmed that nebulizer mouthpieces should always be stored in a bag to prevent contamination. The resident’s MDS showed a BIMS score of 12, indicating moderate cognitive impairment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent verbal abuse towards a resident by a dietary employee. The incident occurred when the resident, who had been admitted to the facility approximately four weeks prior, frequently requested additional or different food. The dietary employee responded rudely and loudly, leading to daily arguments. Despite the resident reporting the issue to the facility administrator and nurses, the dietary employee continued to work at the facility and the verbal altercations persisted. The situation escalated when the dietary employee's boyfriend threatened the resident outside the facility, after being informed about the resident by the dietary employee, resulting in a three-day suspension for the employee. The facility's policy on abuse, neglect, and exploitation clearly states that residents must be free from abuse by anyone, including facility staff. However, the facility's response to the incident was inadequate. The administrator initially treated the incident as poor customer service rather than verbal abuse, and no written statements were obtained from witnesses. The dietary employee received only a written warning and a three-day suspension for a separate HIPAA violation, but continued to work at the facility, leading to further distress for the resident. Interviews with the resident, CNA, and other staff revealed that the dietary employee's behavior was known but not adequately addressed. The CNA who witnessed the altercation failed to remove the resident from the situation, and the administrator did not fully investigate the incident or recognize it as verbal abuse. The facility's failure to protect the resident from verbal abuse and adequately address the dietary employee's behavior resulted in ongoing distress and a threat to the resident's safety.