Holmes County Long Term Care Center - Durant

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure food was reheated and held in accordance with safe food handling standards for one (1) of 1 meal service observed.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program by failing to ensure staff disinfected multi-use glucometers using the manufacturer's required two-minute wet contact time and handled blood-contaminated soiled linens in accordance with facility policy. Specifically, staff failed to properly disinfect multi-use glucometers between resident use for three (3) of four (4) finger-stick blood glucose observations and failed to properly contain and remove blood-contaminated linens for one (1) resident observed on two (2) of three (3) survey days, creating the potential for the transmission of infectious organisms. Findings Include: Review of facility policy titled Handling Soiled Linen updated July 2019, revealed, Policy: [...]

Inspectors wroteBased on observation, record review, facility policy review, and staff interviews, the facility failed to ensure the residents' right to be free from physical restraints for one (1) of nineteen (19) sampled residents. Resident #35 Findings Include: Review of the facility policy titled Physical Restraints revealed, Restraints shall only be used for the safety and well-being of the residents and only after alternatives have been tried unsuccessfully. Record review of Resident #35's Order Summary Report did not reveal a physician order for the use of a seat belt and lack of quarterly assessments for restraints. Record review did not reveal a Care Plan addressing Resident #35s use of the seat belt. During an observation on 7/07/2026 at 11:47 AM, Resident #35 was observed wearing a seat belt while seated in his wheelchair in the dining room. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to timely complete and transmit a discharge Minimum Data Set (MDS) assessment as required by the Centers for Medicare and Medicaid Services (CMS) guidelines for one (1) of nineteen (19) MDS reviews.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to accurately code Section P of the Minimum Data Set (MDS) to reflect the resident's use of physical restraint for one (1) of nineteen (19) residents reviewed for MDS accuracy. Resident #35 Findings Include: Review of facility policy titled, MDS Assessment revealed, It is the policy of this facility to follow the Resident Assessment Instrument (RAI) process as set forth by Centers for Medicare and Medicaid Services (CMS) protocol. Record review of Resident #35's MDS with an Assessment Reference Date (ARD) of 6/24/2026 revealed Section P did not identify the resident's use of a seat belt as a physical restraint during the assessment reference period. [...]

Inspectors wroteBased on record review, resident and staff interview, and facility policy review, the facility failed to notify the State Mental Health Authority of a resident with a significant change in status following an inpatient psychiatric admission for one (1) of four (4) Preadmission Screening and Resident Review (PASRR) reviewed. Resident #6 Findings Include:Record review of the facility policy titled Resident Assessment-Coordination with PASARR Program revealed under, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Additionally revealed under, Policy Explanation and Compliance Guidelines: . 8. [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to develop a comprehensive care plan for restraint use (Resident #35) and for physician-ordered dietary interventions (Resident #76) and the facility failed to implement care plan interventions for pain management (Resident #16) and nail care (Resident #37 and #60) for five (5) of 19 care plans reviewed. Resident #16, Resident #35, Resident #37, Resident #60, Resident #76 Findings Include: Review of the facility policy titled Care Plans-Comprehensive dated 10/2016, revealed, .An individual (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Resident #16 Record review of Resident #16's Care Plan Report revealed, Focus: [...]

Inspectors wroteBased onobservations, staff interviews, record reviews, and facility policy review, the facility failed to follow the standards of nursing practice for three (3) of 24 residents observed during medication and treatment care observations. Resident #15, Resident #21 and Resident #37. Findings Include: Review of facility policy titled, Standards of Nursing Practice, dated 04/26, revealed, It is the policy of this facility to follow (Proper name) Nurse Practice Act and the (Proper name) Board of Nursing Scope of Practice for all standards of nursing care and documentation . Resident #15 During a medication pass observation on 7/9/2026 at 8:37 AM with Licensed Practical Nurse (LPN) #1, she completed Resident #15's scheduled 8:00 AM medication pass; however, she did not administer the physician-ordered 4-ounce house supplement. [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure necessary nail care services were provided for residents requiring assistance for two (2) of eight (8) residents reviewed for activities of daily living (ADLs). Resident #37 and Resident #60 Findings Include: Review of facility policy titled Nail Care Policy dated 2/2026, revealed, .4. Routine nail care, to include trimming and filing, will be provided on a regular schedule identified by the facility. Nail care will be provided between scheduled occasions as the need arises . Resident #37 During observations and interviews with Resident #37 on 7/7/2026 at 12:37 PM and again on 7/9/2026 at 8:38 AM, his fingernails were observed to be approximately one and one-half (11/2) inches in length with a dark brown/black substance underneath. [...]

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to provide uninterrupted enteral feedings for a resident who received nutrition through Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of three (3) residents reviewed with PEG tubes for nutrition. Resident #21 Findings Include: Record review of the facility policy, with no date, titled Transcribing Physician Orders, stated, It is the policy of this facility to follow the attending physician's orders as written . Procedure: Orders will be followed and medications will be administered according to the prescribed physician's instruction Record review of the Medication Administration Record (MAR) revealed a physician's order dated 04/17/26, Enteral feed order two times a day for enteral feeding to run 22 hours daily related to Dysphagia. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure prescribed pain medication was administered and available as ordered for one (1) of six (6) residents interviewed during a Resident Council Meeting. Resident #16Findings Include:Review of the facility policy titled Pain Assessment/Management revealed, It is the policy of this facility to provide guidelines in the identification and treatment of the residents at risk for acute and chronic pain. Each resident's pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .During the Resident Council Meeting on 7/08/2026 at 2:00 PM, Resident #16 stated she had not received her prescribed pain medication since returning from the hospital a week ago. [...]

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, and administering of all drugs and biologicals to meet the needs of each resident for one (1) of 29 medication administrations. Resident #21 Findings Include: Review of facility policy titled, Transcribing Physicians Orders, with no date, revealed, .Orders will be followed and medications will be administered according to the prescribed physician's instructions . Record review of the July 2026 Medication Administration Record (MAR) revealed an active physician's order dated 06/03/23, Scopolamine Transdermal Patch 72 hour, apply one (1) patch transdermal one time a day every three (3) days for increased secretions and remove per schedule. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was five (5) percent (%) or less for two (2) of twenty-nine medication opportunities. Medication error rate of 6.90%Findings Include: Review of facility policy titled Medication Error Rate Policy dated 3/2026, revealed, Policy: The facility is committed to maintaining a medication error rate of less than 5%, in accordance with Centers for Medicare and Medicaid Services (CMS) requirements for long-term care facilities. Medication administration practices will be monitored through routine medication pass observations, audits, and Quality Assurance and Performance Improvement (QAPI) activities . [...]

Inspectors wroteBased on observations, interviews, and facility policy reviewed, the facility failed to properly secure and store medications for two (2) of four (4) medications carts. Medication cart B and Medication cart E. Findings Include: Record review of facility policy titled, Medication Storage in the Facility, with no date, stated, Medications and biologicals are stored safely, securely and properly Observation on [DATE] at 8:40 AM during medication administration on B hall medication cart revealed a bottle of liquid vitamin with an expiration date of 06/26. Interview with Licensed Practical Nurse (LPN) #1 confirmed that the liquid vitamin was expired and was in use for a resident and stated, Pharmacy comes once a month and usually checks our med carts for expired stuff and removes it, but I guess that one got missed. [...]

Inspectors wroteBased on observation, resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure hot meals were served at a palatable temperature for two (2) of four (4) residents reviewed for dining services. Residents #6 and #43Findings Include:Review of the facility policy titled Food Palatability Policy dated 4/26 revealed under, Purpose: To ensure all residents receive meals that are palatable, appetizing, nutritious, and served at appropriate temperatures to promote adequate nutritional intake, resident satisfaction, and quality of life. Also revealed under, Procedure: . 2. Hot foods will be served hot . 6. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide the necessary care and services to meet a resident's nutritional needs by failing to implement a physician-ordered dietary intervention for one (1) of fifty-six (56) residents reviewed.

Inspectors wroteBased on interviews, facility policy review, and record reviews, the facility failed to implement the care plan for a two (2) person assist with the use of a full body mechanical lift for all transfers of Resident #4. Resident #4 sustained a head injury and received medical treatment at the emergency room (ER) as a result of the misuse of the full body mechanical lift. Resident #4 was one (1) of four (4) sampled residents in the facility identified as dependent upon the full body mechanical lift with two (2) persons assistance for transfers. Based on the facility's implementation of corrective actions on 11/06/24 through 11/11/24, the State Agency (SA) determined the deficiency to be Past Non-Compliance.

Inspectors wroteBased on interviews, facility policy reviews, and record reviews, the facility failed to prevent an injury of a resident by not following the established facility policies and procedures for the use of two (2) person assistance with a full body mechanical lift for all transfers. Resident #4 had to seek medical care at the emergency room (ER) for a laceration to her head which required closure with staples. Resident #4 was one (1) of four (4) sampled residents dependent upon full body mechanical lifts for all transfers. Based on the facility's implementation of corrective actions on 11/06/24 through 11/11/24, the State Agency (SA) determined the deficiency to be Past Non-Compliance. Findings Include: [...]

Inspectors wroteBased on observation, staff interview, resident representative interview, and facility policy review, the facility failed to ensure that each resident was treated with dignity as evidenced by failure to cover unclothed residents that were visible from the hallway, and failure to provide a privacy bag for a catheter for three (3) of twenty-two sampled residents. Resident #5, Resident #55 and Resident #228.

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to ensure a residents call light was within reach for one (1) of 22 residents sampled. Resident #24 Findings Include Review of the facility policy titled, Call Light, Answering with no revision date revealed under, Key Procedural Points .#5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. An observation and interview on 06/25/24 at 8:15 AM, revealed Resident #24 was sitting on the side of the bed receiving Oxygen (O2) via (by) nasal cannula. The resident stood up and said she needed to go to the bathroom, with no shoes on and nasal cannula still attached, she attempted to take two steps and stated she needed help, but admitted she did not know where her call light was located. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan for a resident with Activities of Daily Living (ADL) diabetic nail care and failed to implement a comprehensive care plan for a resident with ADL nail care for two (2) of the twenty-two sampled residents.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide personal hygiene as evidenced by long, jagged nails with a brown substance underneath the fingernails for two (2) of the twenty-two sampled residents.

Inspectors wroteBased on observation and staff interview the facility failed to prevent the possibility of an accident and hazards as evidenced by not properly securing and storing chemicals for one (1) of three (3) survey days. Findings Include: Review of the typed statement on facility letterhead revealed the facility did not have a policy on chemical cleaners in the whirlpool room. However, they are expected to be in a locked cabinet when not in use and this was signed by the Administrator. An observation and interview on 6/26/24 at 10:45 AM with Licensed Practical Nurse (LPN) #1 revealed the shower room on the B-Hall had a coded lock on the door, but LPN #1 turned the door handle and walked in without using the keyed lock. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure a controlled substance was signed out on a resident's narcotic administration log at the time of administration for one (1) of five (5) residents observed during medication pass (Resident #31) and during one (1) of two (2) narcotic log reconciliations.

Inspectors wroteBased on staff interview and record review, the facility failed to submit a status change for a resident with a new mental illness diagnoses for one (1) of four (4) Pre-admission Screening and Record Reviews (PASARR) reviewed.

Inspectors wroteBased on staff interviews, pharmacy consultant interview and record review, the facility failed to ensure a resident on a PRN (as needed) psychotropic medication had a stop date for one (1) of six (6) resident's medication reviewed.