Noxubee County Nursing Home

Inspectors wroteBased on staff interview and record review the facility failed to timely revise and implement a comprehensive, person-centered care plan for one (1) of eight (8) residents at risk for aspiration and choking risk. Resident #1. The facility's failure to revise the care plan and provide supervision on [DATE] at 11:20 AM, resulted in serious injury and death for Resident #1, who had a documented aspiration/choking risk. Resident #1 was not provided supervision while eating when staff served his lunch meal and stepped away from the table. Resident #1 began choking and required transfer to the emergency department where he was intubated and air lifted to another hospital for a higher level of care. Resident #1 expired after being taken off the ventilator on [DATE]. [...]

Inspectors wroteBased on review of facility investigation, staff interviews and record review the facility failed to provide adequate supervision and assistance during meals for one (1) of eight (8) residents at risk for aspiration and choking risk. Resident #1. The facility's failure to provide supervision on 5/4/26 at 11:20 AM, resulted in serious injury and death for Resident #1, who had a documented aspiration/choking risk. Resident #1 was not provided supervision while eating when staff served his lunch meal and stepped away from the table. Resident #1 began choking and required transfer to the emergency department where he was intubated and air lifted to another hospital for a higher level of care. Resident #1 expired after being taken off the ventilator on 5/8/26. [...]

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to maintain a clean and homelike environment as evidenced by a dirty air conditioning unit in one (1) of 30 rooms observed. room [ROOM NUMBER]. Findings Include: Review of the facility policy, Routine Cleaning and Disinfection with revision date of February 2023, revealed, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . An observation on 06/09/25 at 11:23 AM and on 06/11/25 at 2:55 PM, in room [ROOM NUMBER], revealed a dirty air conditioning unit that had a damp, black substance scattered on the plastic slats on the front panel. [...]

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to address a grievance regarding answering a call light and providing Activities of Daily Living (ADL) care in a timely manner for one (1) of the 17 sampled residents.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure an as needed (PRN) psychotropic hypnotic medication for insomnia was limited to 14 days or to an appropriate time frame approved by the provider for one (1) of five (5) medication reviews.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a person-centered care plan for providing incontinent care for one (1) of the 18 care plans reviewed.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADLs) with incontinent care was provided for one (1) of 17 sampled residents.

Inspectors wroteBased on staff interview, record review, and facility letterhead review, the facility failed to monitor residents for side effects of anticoagulant medication use for two (2) of five (5) medication reviews.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medications were stored properly in a secure manner in the medication cart for one (1) of five (5) medication administration observations. Findings Include: Review of the facility policy titled Medication Storage, undated, revealed .1. General Guidelines: c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . An observation on 06/11/25 at 9:05 AM, revealed a medication card of Lasix tablets on top of an unattended medication cart. An observation revealed Licensed Practical Nurse (LPN) #1 walked away from the medication cart down to the end of the hall in the sitting area and assisted a resident in a wheelchair to her room to receive her medications. [...]

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to utilize protective barriers to prevent possible contamination and spread of bacteria during two (2) of five (5) resident medication administration observations. Resident #1 and Resident #43. Findings Include: Review of the facility policy, Administration of Eye Drops or Ointments Policy with revision date of 04/24/23 revealed, Eye medications are administered as ordered by the physician and in accordance with professional standards of practice .5. Administration: a. Remove medication cap and place on clean, dry surface (i.e. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to accurately complete a Minimum Data Set (MDS) assessment as evidenced by the presence of a pressure ulcer not being indicated on the assessment for one (1) of 16 MDS assessments reviewed. Resident #50 Findings Include: Review of the facility policy titled, MDS 3.0 Completion with an implementation date of 6/14/21 and no revision date revealed under the Policy .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. An interview on 10/18/23 at 8:45 AM, with Registered Nurse (RN)/Treatment Nurse #1 revealed that Resident #50's pressure ulcer was facility acquired and was currently still receiving treatment to the heel that started in July of this year. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to implement a care plan regarding the placement of hand rolls per physician's order for one (1) of 16 care plans reviewed.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to place hand rolls on a resident with contractures for one (1) of 25 residents reviewed with contractures.

Inspectors wroteBased on observations, facility policy review, record reviews, and staff interviews the facility failed to prevent the likelihood of infection, as evidenced by failure to change the water flush bag and feeding tube bag every 24 hours for one (1) of six (6) residents reviewed with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Resident #35 Findings Include: Record review of facility policy titled, Gastrostomy Tube Feedings Continuous Feeding Per Pump, dated 12/21/21, revealed . 6. Bottles of formula and/or feeding bags are to be changed every 24 hours . An observation on 06/06/22 at 1:38 PM revealed Resident #35's PEG tube feeding bag was empty and a filled water flush bag. Both bags were hanging on the PEG feeding pump pole and was labeled with the date of 6/4/22 on each bag. An observation and interview on 6/6/22 at 1: [...]