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 Trend Health & Rehab Of Carthage Llc during CMS and state inspections, most recent first.
Privacy in receiving mail was not maintained when the Administrator opened packages addressed to two cognitively intact residents before delivering them. Residents reported in Council that staff had opened their mail to check for contraband, and the Administrator confirmed the packages were opened based on suspicion and prior experiences rather than with the residents’ permission or presence. The facility policy stated residents have the right to privacy in sending and receiving mail.
Advance directives were not consistently maintained in resident charts for two residents. Staff found that some documents were kept in admission packets in the business office instead of being placed in the chart, and an RN, the Regional Consultant, and the DON confirmed they were not readily accessible to staff at all times. For both residents, the EHR did not contain an advance directive, although a paper Code Status Form was filed under the Advance Directive tab.
An LPN left an opened Lantus insulin pen without an opening date on a medication cart, and another LPN found an unopened Levemir insulin vial and three Spikevax COVID-19 vaccine syringes available for use after their expiration dates in a medication refrigerator. The DON confirmed medications should be dated when opened and expired insulin and vaccines should be removed from use.
Food was repeatedly served below required hot-holding temperatures, with survey testing showing breakfast items such as eggs, sausage, and grits below the facility’s 135 degrees F standard and other hot foods also measuring low. Residents reported that meals, especially breakfast, were often cold, and concerns were raised in resident council. The Dietary Manager confirmed the items did not meet the expected temperature range, and the Administrator acknowledged that hot foods should be served at proper temperatures.
A resident with expressive language disorder and cognitive communication deficit was not provided consistent access to her communication board and whiteboard. The DON and Speech Therapist confirmed the communication aids were kept in a drawer or on a charger rather than within the resident’s reach, and an LPN reported the board had not been in the resident’s room. The resident stated she had difficulty being understood and wanted the board available at all times to help her express her needs.
Failure to provide ordered ADL and hygiene care for a resident with severe cognitive impairment, hemiplegia, and COPD. The resident was observed with long jagged fingernails with black debris, flaking skin on a long beard, strong body odor, and strong oral odor while receiving PEG tube feeding. Active orders required mouth care and teeth brushing every shift and weekly nail care, and staff described a bathing and nail care schedule that did not match the observed condition.
The facility did not adequately investigate, address, or resolve repeated grievances about food quality and temperature raised through Resident Council meetings. Over several months, residents reported that weekend meals were bad, food was consistently cold, beverages lacked sufficient ice, and breakfast items were hard or unpalatable. While limited steps such as using temperature-holding containers, sending trays out faster, and in-servicing dietary staff were noted, there was no documented monitoring, follow-up, or evaluation of effectiveness. Cognitively intact residents continued to report cold, poor-tasting food, and staff, including the Dietary Manager and Social Services, acknowledged awareness of the complaints without evidence of thorough follow-up or resolution.
A resident with multiple chronic conditions and severe cognitive impairment did not receive an increased dose of Lasix as ordered by a nephrologist because staff failed to obtain and implement the new order after a consultation. The consultation paperwork was not entered into the record, and staff did not follow up to ensure the medication change was made, resulting in the resident experiencing worsening edema and requiring hospital transfer.
A long-term care facility failed to protect residents from abuse and neglect, as evidenced by two incidents. In one case, a CNA verbally and physically abused a non-English-speaking resident, witnessed by a cognitively intact roommate. The CNA was terminated after the abuse was confirmed. In another case, a resident fell from a mechanical lift due to improper use by a CNA, resulting in a head injury and hip fracture. Initial staff statements were inconsistent, and some later admitted to falsifying their accounts. The facility's investigation was inadequate, failing to initially uncover the truth about the incident.
A resident with severe cognitive impairment fell from a mechanical lift during a transfer, resulting in a head injury and fracture. The CNA operated the lift alone, contrary to facility policy. Initial reports falsely indicated multiple staff were present, but later confessions revealed the CNA acted alone. The facility's investigation was inconsistent and did not follow proper procedures.
A resident with a history of cerebrovascular accident and severe cognitive impairment fell and sustained injuries due to a CNA's failure to follow the care plan requiring two-person assistance for mechanical lift transfers. The CNA attempted the transfer alone, contrary to facility policy, resulting in a fall and serious injury. Initial reports inaccurately stated multiple staff were present, but later interviews confirmed the CNA acted alone.
A resident in a long-term care facility suffered a forehead injury and a right femoral fracture after being improperly transferred with a mechanical lift by a single CNA, contrary to the facility's two-person lift policy. The resident, who was severely cognitively impaired, required surgery following the incident. Initial staff statements were inconsistent, and further confessions revealed that the CNA operated the lift alone, leading to the accident.
The facility failed to accurately complete the MDS assessment for a resident by incorrectly coding indwelling catheter usage during the 7-day observation look-back period. The resident's catheter had been removed weeks prior, but the MDS assessment did not reflect this change, resulting in an inaccurate portrayal of the resident's condition.
A resident with left-sided hemiplegia following a CVA had a care plan requiring mouth care every shift. Observations revealed the resident's lips were cracked, dry, and had crusty scaling. The DON confirmed that oral hygiene was not performed as required by the care plan.
A facility failed to provide adequate oral care for a resident on enteral nutrition, resulting in dry, cracked, and crusty lips. Despite facility policy requiring oral care every shift, observations and staff interviews confirmed that oral hygiene was not performed as needed, causing discomfort for the resident.
Privacy in Receiving Mail
Penalty
Summary
The facility failed to protect residents’ privacy in receiving mail when packages addressed to two cognitively intact residents were opened by the Administrator before being delivered to them. Resident Council concerns were raised by nine residents, including the Resident Council President, who reported that staff had opened residents’ mail before delivery and said staff told them the mail was opened to check for contraband. The facility policy titled Resident Rights stated residents have the right to privacy in sending and receiving mail and that the facility would make every effort to assist each resident in exercising those rights. During interviews, the Activities Director stated the Administrator or Business Office Manager retrieved residents’ mail and packages from the mailbox and that mail was then distributed by Activities or Social Services staff. The Activities Director confirmed residents had the right to receive and open mail and packages privately, but stated the Administrator had opened packages addressed to two residents because of concerns that the packages contained prohibited substances. The Administrator confirmed opening the packages before delivery based on suspicion and prior experiences, stating one resident had previously received contraband in a package and another had ordered a similar prohibited product. Record review showed both residents had BIMS scores of 15, indicating they were cognitively intact, and the Administrator’s signed statement confirmed the packages were opened without documenting resident permission or presence.
Advance directives were not consistently maintained in resident charts
Penalty
Summary
The facility failed to ensure residents' advance directives were maintained in the medical record and readily accessible to staff for 2 of 20 sampled residents, Resident #5 and Resident #46. Survey staff found that some advance directives were kept in admission packets in the business office rather than in the medical record. Facility staff confirmed that these documents should have been included in the residents' charts so they would be available to staff at all times. Facility policy stated that if a resident has an advance directive, copies are to be made and placed on the chart and communicated to staff upon admission. During interviews, an RN stated that the chart contained the code status form as the advance directive, but this form only identified whether the resident was full code or DNR. The Regional Consultant and DON both acknowledged that some advance directives were filed in the business office and were not readily accessible on the chart. Resident #5 had diagnoses including Expressive Language Disorder and Cognitive Communication Deficit, with an MDS BIMS score of 11 indicating moderate cognitive impairment. Resident #46 had diagnoses including COPD and Depression, with an MDS BIMS score of 14 indicating intact cognition. For both residents, the electronic health record did not contain an advance directive, while a paper Code Status Form was located under the Advance Directive tab.
Medications Left Unlabeled and Expired
Penalty
Summary
The facility failed to ensure medications were properly labeled, dated, and stored in one medication room on South Hall and one medication cart on North Hall. During observation of the North Hall long medication cart with an LPN, one opened Lantus insulin pen prescribed for Resident #33 was available for use without a label showing the date it was opened. The LPN confirmed the pen was open and in use but did not have an opening date, and acknowledged staff could not determine whether it remained within the manufacturer's recommended use period without that information. During observation of the South Hall medication room refrigerator with another LPN, one unopened vial of Levemir insulin prescribed for Resident #16 was available for use after the manufacturer's expiration date, and three floor-stock syringes of Spikevax 2025-2026 COVID-19 vaccine were also available for use after their expiration date. The LPN confirmed the insulin and vaccine syringes remained available beyond their expiration dates and stated expired insulin could lose potency and expired vaccines could lose potency and fail to provide intended protection. The DON stated expired insulin and vaccines should be removed from use and confirmed medications should be labeled with the opening date when first opened and monitored for expiration.
Cold Meals Served Below Required Hot-Holding Temperatures
Penalty
Summary
Food was not maintained at palatable hot-holding temperatures for multiple meals, with survey observations and resident interviews showing that hot items were frequently served cold or below the facility’s stated temperature standard. The facility policy for Monitoring Temperatures of Cooked Foods required TCS cooked foods to be held at 135 degrees Fahrenheit or higher, but survey testing found several items below that level, including pureed meats at 120 degrees F, pureed tomatoes at 120 degrees F and 105 degrees F, fried steak at 122 degrees F, and chopped meat at 115 degrees F. During a breakfast tray test, eggs measured 102 degrees F, a biscuit 100 degrees F, sausage 99 degrees F, and grits 120 degrees F; the grits were warm, but the sausage and eggs were cold to the palate. Residents reported ongoing concerns that meals were cold, especially breakfast. Two residents stated that food was cold even when trays were delivered promptly, and one resident said staff told him they were not allowed to heat the food. The resident also stated the issue had been brought up repeatedly in resident council and that staff said they would fix it but never did. During the resident council meeting, multiple residents voiced that meals were frequently served cold and that coffee was often cold by the time it was received. The Dietary Manager acknowledged that hot foods should be served at 135 to 140 degrees F and confirmed that the tested breakfast items did not meet that range. He also stated that complaints about cold food had been received about three months earlier and that the facility’s heating equipment had not changed. The Administrator stated that hot foods should be served at 135 degrees F and that serving food at improper temperatures could lead to palatability issues and possible nutritional problems such as weight loss. The affected residents had intact cognition, with diagnoses including cerebral infarction with hemiplegia and hemiparesis, and one resident was on a mechanical soft diet with regular texture and regular liquids while the other was on a low concentrated sweets diet with regular texture and regular liquids.
Communication Board Not Kept Accessible for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of a resident’s needs by not ensuring that communication supports were consistently accessible and available to assist the resident in expressing needs. The facility policy on Promoting/Maintaining Resident Self Determination stated that staff members involved in providing care would promote and facilitate resident self-determination through support of resident choice. Resident #5 stated that she had difficulty being understood and previously used a communication board, but had not seen it in quite some time. She said she wanted to communicate freely with others and that having the board available at all times would help her express her needs. During interviews, an LPN reported she did not recall the resident ever having access to a communication board and said the board had been found on its charger rather than in the resident’s room. The DON confirmed the resident had a communication board but said it was kept in a drawer instead of being accessible at bedside. The Speech Therapist stated the resident had an electronic communication board and a whiteboard, but the electronic board was placed in the bottom nightstand drawer and the resident had to use the call light for staff to retrieve it because she could not access it independently. The resident’s record showed diagnoses of Expressive Language Disorder and Cognitive Communication Deficit, and the MDS reflected a BIMS score of 11, indicating moderate cognitive impairment.
Failure to Provide Ordered ADL and Hygiene Care
Penalty
Summary
The facility failed to ensure Activities of Daily Living were provided in accordance with physician orders for one resident. Resident #54 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and chronic obstructive pulmonary disease, and the quarterly MDS indicated severe cognitive impairment with staff assistance required for all ADLs. The resident was observed lying in bed receiving continuous PEG tube feeding, with fingernails on both hands jagged and about one-quarter inch beyond the fingertips, black substance under the nails, a long beard with flaking skin, and a very strong musty, unpleasant body odor from the PEG tube area. Follow-up observations showed the resident's fingernails remained long, jagged, and unclean, with a continued very strong musty body odor, and a strong unpleasant odor from the resident's mouth was also noted. The resident had active orders for mouth care every shift with teeth brushing every shift, and for nails to be gently smoothed with an emery board and cleaned with a denture brush using soap and water once weekly on Mondays. RN #1 stated the bathing schedule included bed baths on Mondays, Tuesdays, Thursdays, and weekends, with showers on Wednesdays and Fridays, and that CNAs gently filed and cleaned the resident's nails on Mondays while an RN performed diabetic nail care on Thursdays.
Failure to Investigate and Resolve Ongoing Food-Related Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced through the Resident Council regarding food quality and temperature were thoroughly investigated, addressed, and resolved. Resident Council minutes over multiple months documented repeated complaints that weekend food was "bad," tasted sweet, and that food was cold by the time it reached residents. Additional concerns included insufficient ice in water and tea, hard breakfast biscuits and toast, and cold grits. Although the facility’s grievance policy stated that residents and families could voice grievances without reprisal and that the facility would make prompt efforts to resolve grievances, there was no documentation that the initial complaint about weekend food quality was addressed, and subsequent complaints continued without evidence of thorough investigation or resolution. Resident Council Department Response Forms showed limited actions, such as placing food in containers to maintain temperature, conducting an in‑service for dietary staff, sending food out faster, and instructing staff to pass trays promptly, but there was no documentation of monitoring, follow‑up, or evaluation of whether these measures were effective. Residents interviewed, all cognitively intact per their MDS BIMS scores, consistently reported that the food remained cold and did not taste good, with one resident noting that staff would reheat food only if requested. The Dietary Manager acknowledged awareness of the complaints and stated he had spoken with weekend staff and made changes like replacing tray carts and providing guidance on food preparation, but confirmed there was no documentation of ongoing monitoring or additional interventions. Social Services and the Administrator both acknowledged awareness of the complaints and that additional follow‑up and resolution efforts should have occurred, yet no evidence of such follow‑up was present in the records.
Failure to Implement Physician-Ordered Medication Change
Penalty
Summary
Staff failed to ensure a resident received necessary care and services in accordance with physician orders when they did not obtain and implement a nephrologist's order to increase Lasix. After a nephrology appointment, the nephrologist ordered an increase in Lasix to 40 mg twice daily, and the resident's family provided the consultation paperwork to facility staff. However, the order was not entered or implemented until seventeen days later. During this period, the resident experienced worsening leg swelling and weakness, and therapy was discontinued. The consultation paperwork was not found in the resident's record, and staff did not follow up to obtain the missing orders from the provider. Interviews with the DON, medical records staff, and unit manager confirmed that the process for handling consultation forms was not followed, and no follow-up occurred when the form was missing. The resident, who had chronic obstructive pulmonary disease, pulmonary hypertension, diastolic heart failure, and chronic kidney disease, was severely cognitively impaired at the time. The resident ultimately required hospital transfer due to increased edema and fever, and was admitted with edema and a urinary tract infection.
Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by two separate incidents involving a Certified Nursing Assistant (CNA) and the improper use of a mechanical lift. In the first incident, a CNA was reported to have verbally and physically abused a resident who was unable to speak English but could understand it. The abuse was witnessed by the resident's roommate, who was cognitively intact and provided consistent accounts of the abuse. The facility's administration was informed of the CNA's previous termination from another facility for similar abuse, and the CNA was subsequently terminated after an investigation confirmed the abuse. In the second incident, a resident who required assistance with a mechanical lift was neglected when a CNA attempted to transfer the resident alone, contrary to facility policy requiring two staff members for such transfers. The resident fell from the lift, sustaining a head injury and later being diagnosed with a hip fracture. Initial statements from staff involved were inconsistent, with some staff members later admitting to falsifying their accounts of the incident. The facility's investigation was found to be inadequate, as it did not initially uncover the truth about the number of staff present during the transfer. Both incidents highlight significant lapses in the facility's adherence to its policies and procedures designed to protect residents from harm. The failure to prevent abuse and ensure proper use of mechanical lifts resulted in physical harm to residents and demonstrated a lack of effective oversight and communication among staff and administration.
Failure to Investigate Mechanical Lift Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a fall from a mechanical lift, resulting in a head injury and a fracture requiring surgical repair for a resident. The incident occurred when a CNA attempted to transfer the resident from a bed to a wheelchair using a mechanical lift. The CNA operated the lift alone, despite the facility's policy requiring assistance from another staff member. During the transfer, the lift tilted, causing the resident to fall and sustain injuries. Interviews with staff revealed inconsistencies in their accounts of the incident. Initially, it was reported that multiple staff members were present during the transfer, but later confessions indicated that the CNA operated the lift alone. The LPN and other CNAs who were initially reported to be present later admitted they were not in the room at the time of the fall. This discrepancy highlights a failure in the facility's investigation process, as the DON did not accurately capture the events leading to the resident's injury. The facility's investigation was not conducted in accordance with its policies and procedures, which require thorough investigation and suspension of involved staff during the investigation. The DON's report was inconsistent with the statements provided by the staff, and the facility's leadership was unaware of the true circumstances of the incident until after the survey. The resident involved was severely cognitively impaired and had a history of cerebral infarction, which may have contributed to the complexity of her care needs.
Failure to Implement Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement the care plan for a resident requiring transfer with a mechanical lift, resulting in a fall and serious injury. The care plan specified that the resident, who had a history of cerebrovascular accident and was severely cognitively impaired, required a total lift for transfers with the assistance of two persons. However, during a transfer, a CNA attempted to use the mechanical lift alone, which led to the resident falling and sustaining a head injury and a hip fracture. Interviews and record reviews revealed that the CNA responsible for the transfer was aware of the requirement for two-person assistance but proceeded alone due to nervousness and confusion. The CNA admitted to placing the sling under the resident and lifting them without waiting for additional help. This action was contrary to the facility's policy, which mandates that all mechanical lifts require two persons to assist with the operation and ensure the resident's safety. The facility's administration, including the ADON and ADM, confirmed that they were unaware of the incident's true circumstances until after the survey. Initially, the DON's investigation report inaccurately stated that three CNAs and an LPN were present during the incident. However, subsequent re-interviews revealed that the CNA had acted alone, and the other staff members were not present at the time of the fall. This discrepancy highlights a failure in communication and adherence to established care protocols, leading to the resident's injury.
Failure to Follow Lift Protocol Results in Resident Injury
Penalty
Summary
The facility failed to prevent a preventable accident involving a resident who was transferred using a mechanical lift without the required two-person assistance. The incident resulted in the resident sustaining a forehead injury and a right intertrochanteric femoral fracture, necessitating surgery. The resident was transferred to the hospital emergency room twice due to the accident. The facility's policy clearly stated that the use of a mechanical lift required two nursing assistants, but this protocol was not followed. The investigation revealed inconsistencies in the statements provided by the staff involved. Initially, it was reported that three CNAs and an LPN were present during the transfer, but further interviews and confessions indicated that CNA #2 operated the lift alone. CNA #2 admitted to starting the lift procedure before the arrival of the second CNA, which was against the facility's policy. The LPN and other CNAs later confessed to not being truthful in their initial statements, confirming that CNA #2 was alone during the transfer. The resident involved was severely cognitively impaired and dependent on staff for all needs, making adherence to the two-person lift policy crucial. The facility's investigation was not conducted in accordance with its policies, and the DON's report was inconsistent with the staff's statements. The incident highlights a significant lapse in following established safety protocols, leading to a serious injury for the resident.
Inaccurate MDS Assessment for Indwelling Catheter Usage
Penalty
Summary
The facility failed to accurately complete section H of the Minimum Data Set (MDS) assessment for a resident, as evidenced by incorrectly coding indwelling catheter usage during the 7-day observation look-back period. Specifically, Resident #57 was coded for having an indwelling catheter in the MDS assessment with an Assessment Reference Date (ARD) of April 15, 2024, despite the catheter being discontinued on February 19, 2024. This error was confirmed by the MDS Nurse, who acknowledged that the resident did not have an indwelling catheter during the look-back period from April 9 through April 15, 2024, and admitted that the assessment was submitted in error. Interviews with the Director of Nurses (DON) and the MDS Nurse revealed that Resident #57's catheter had been removed approximately six weeks prior to the assessment period. The facility's policy on MDS corrections, dated October 2019, emphasizes the importance of accurate MDS data to ensure proper resident assessment and care planning. However, the failure to update the MDS assessment to reflect the removal of the catheter resulted in an inaccurate portrayal of the resident's condition. Resident #57 was admitted to the facility with diagnoses including Type 2 Diabetes Mellitus and Hemiplegia and Hemiparesis.
Failure to Implement Comprehensive Care Plan for Mouth Care
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident requiring mouth care. The care plan for the resident, who had left-sided hemiplegia following a cerebral vascular accident (CVA), specified that mouth care should be provided every shift. However, observations on multiple occasions revealed that the resident's upper and lower lips were cracked, dry, and had a crusty yellowish scaling of the skin. The Director of Nursing (DON) confirmed that oral hygiene had not been performed as required by the care plan, acknowledging that the staff did not follow the care plan for oral hygiene.
Failure to Provide Oral Care for Resident on Enteral Nutrition
Penalty
Summary
The facility failed to provide adequate oral care for a resident receiving enteral nutrition, as evidenced by observations of dry, cracked, and crusty areas on the resident's upper and lower lips. The facility's policy required oral care assistance each morning, at bedtime, and as needed. However, multiple observations on different days revealed that the resident's lips were in poor condition, indicating a lack of proper oral hygiene. The resident had medical diagnoses including Dysphagia following Cerebral Infarction, Gastrostomy status, and Unspecified Dementia, and had orders for strict NPO status and mouth care every shift. During an interview, a CNA assigned to the resident confirmed that oral hygiene had not been performed that day, despite recognizing the resident's dry lips. The CNA admitted to not returning to provide oral care after initially finding the resident receiving a bed bath. The Director of Nursing also confirmed that oral hygiene had not been performed and acknowledged that the resident's dry, chapped lips required moisturizing for hydration. The failure to provide necessary oral care was discomforting for the resident and did not comply with the facility's policy.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Carthage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carthage Senior Care | 0.2 mi | ★★★★★ | 5 | 0 |
| Attala County Nursing Center | 22.7 mi | ★★★★★ | 0 | 0 |
| Choctaw Residential Center | 23.5 mi | ★★★★★ | 2 | 0 |
| Neshoba County Nursing Home | 24.1 mi | ★★★★★ | 10 | 1 |
| Hilltop Manor Health And Rehabilitation Center | 26.1 mi | ★★★★★ | 1 | 0 |
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