Mississippi Nursing Home Cited for Care Plan Failures and Inadequate Personal Hygiene Assistance
CANTON, MS - Federal inspectors documented multiple violations at Forest Hill Nursing Center following a March 2025 inspection, finding that staff failed to implement physician-ordered care plans, left residents without proper grooming assistance for extended periods, and did not follow medical protocols for a dialysis patient's nutritional needs.
Dialysis Patient's Nutritional Orders Left Unimplemented for Weeks
Inspectors identified significant concerns regarding the nutritional care of a resident receiving dialysis treatment. The facility's registered dietician documented recommendations on February 18, 2025, to adjust the resident's tube feeding formula and fluid restrictions after consulting with the dialysis center's dietician. The dialysis team had clarified that the resident required a strict 1,000-1,200 milliliter daily fluid restriction rather than the 1,500 milliliters documented in facility orders.
The dietician's note specifically recommended changing the tube feeding to a more concentrated formula that would provide adequate nutrition for weight gain and wound healing while respecting the lower fluid limitation required for dialysis patients. The recommendation included switching to Nutren 2.0 formula administered five times daily with reduced water flushes, and adjusting medication administration flushes from standard amounts to just 15 milliliters before and after medications.
However, a review of the resident's medication administration records revealed these critical recommendations were never implemented. The resident continued receiving the original feeding formula with higher fluid volumes despite the documented fluid overload issues that prompted the dietician consultation.
In dialysis patients, fluid management represents a critical component of care. When kidneys fail to remove excess fluid adequately, it accumulates in the body, leading to fluid overload. This condition creates pressure on the cardiovascular system, potentially causing pulmonary edema where fluid builds up in the lungs, making breathing difficult. Excess fluid also elevates blood pressure and strains the heart, increasing risks for heart failure and other cardiovascular complications.
The facility's Director of Nursing acknowledged during interviews that she recalled discussing the dietician's recommendations but could not locate the documentation. She admitted the recommendations "must have been misplaced" and confirmed the physician was never notified of the needed changes. The DON stated she did not contact the physician by telephone because she expected the nurse practitioner to visit the facility within a couple of days and could review it then.
This delay in implementing critical nutritional modifications meant the resident continued receiving inappropriate fluid volumes for nearly three weeks. The dialysis center faxed updated physician orders on February 20, 2025, specifying the 1,200 milliliter fluid restriction, but the facility had still not adjusted the feeding regimen by the time of the March inspection.
Widespread Personal Hygiene Care Deficiencies Documented
Inspectors observed four residents with significant unmet grooming needs, including unkempt hair, extended facial hair growth, and inadequate bathing assistance. These observations revealed systemic failures in providing basic activities of daily living care.
One resident was found with facial hair approximately three-quarters of an inch long on his chin, face sides, and neck area, with thick, unkempt hair. During an interview, the resident stated "the barber hasn't been here in quite some time" and expressed his desire for a haircut and shave. He noted that no one had asked him about these grooming preferences. Records revealed his last haircut occurred in October 2024—nearly five months prior to the inspection. This resident's care plan included an intervention to "shave resident as needed," which staff had not implemented.
Another resident presented with facial hair approximately one and a half inches long extending to his cheeks, chin, and neck, along with long, greasy hair. He confirmed "it's been a long time" since receiving grooming care and expressed his desire for these services. A third resident had greasy hair with visible white flakes around the scalp edges and noticeable facial hair. He could not recall when his hair was last washed or when he was shaved but clearly wanted this care provided.
A fourth resident with severe cognitive impairment was observed with oily facial hair and hair that appeared unwashed. Staff documentation showed only two days of personal hygiene care recorded over a two-week period, despite the resident being coded as completely dependent for personal hygiene assistance.
Personal hygiene maintenance serves essential health functions beyond appearance and dignity. The skin acts as the body's first defense barrier against infection, and inadequate cleansing allows bacteria, fungi, and other pathogens to proliferate. For immobile or dependent residents, this creates heightened risks for skin breakdown, fungal infections, and secondary complications. Accumulated oils, dead skin cells, and environmental debris can lead to dermatitis, folliculitis, and other skin conditions that compromise skin integrity.
When staff interviewed confirmed these grooming deficiencies, they acknowledged responsibility for addressing residents' grooming needs but could not explain why care had not been provided. One certified nursing assistant stated she was "not sure" if her assigned resident wanted to be shaved because she "had not asked" and confirmed she should have placed him on the barber list. Another CNA confirmed her assigned resident "was looking rough" but couldn't recall how long it had been since he received grooming care.
Care Plans Failed to Reflect Actual Resident Needs
Beyond the failure to implement existing care plans, inspectors found that care plans were not developed to adequately address residents' documented needs. Several residents requiring extensive assistance with personal hygiene had care plans that either lacked specific interventions or were too vague to guide staff in providing necessary care.
One resident's care plan indicated he required extensive assistance with personal hygiene related to muscle weakness, decreased mobility, pain, and fall history, but the interventions section simply stated "resident requires extensive assistance with personal hygiene" without specifying what care should be provided or how frequently.
Another resident's care plan focused on his need for assistance related to incontinence, dementia, and muscle weakness but contained no interventions related to personal hygiene assistance whatsoever. A third resident's care plan documented the need for assistance with activities of daily living but similarly lacked personal hygiene interventions.
The Medicare Nurse acknowledged during interviews that these care plans were "very vague about the interventions needed for their hygiene and grooming needs." She confirmed that comprehensive care plans should "paint a thorough picture of the resident's individualized needs" so that "anyone can look at their care plan and know exactly their needs." The facility's own policy stated that care plans must include "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs."
Proper care planning forms the foundation of individualized nursing home care. When care plans lack specificity, staff members—particularly those who may be newer or less familiar with individual residents—cannot reliably provide consistent, appropriate care. This becomes especially problematic across shift changes and with varying staff assignments. Care plans translate assessment findings and physician orders into actionable daily care routines that ensure residents receive the services they need.
Restraint Use Without Proper Assessment
Inspectors also identified improper use of physical restraints when they found a resident with both bed and wheelchair alarm pads that restricted his movement. During observation and interview, the resident stated he "hated" the bed alarm because it went off frequently. He reported that when the alarm sounded, he stopped moving to silence it.
A certified nursing assistant confirmed she had observed the resident stopping movement or attempts to get up when the alarm activated because "he did not want it to continue." According to federal guidelines and the facility's own policy, any device that restricts a resident's freedom of movement or causes them to modify their behavior to avoid triggering it constitutes a physical restraint requiring proper assessment, physician orders, and monitoring.
The resident had a physician order for a wheelchair alarm pad but no order for the bed alarm. The Medicare Nurse confirmed that if the resident stated he stops moving to silence the alarm and staff observed this restrictive behavior, both devices would be considered restraints requiring proper restraint assessments—which had not been completed. The Director of Nursing stated she was unaware the resident had voiced concerns about the alarm or that it caused him to modify his movements, and she didn't know when or by whom the bed alarm had been placed.
Physical restraints, even those presented as "safety" devices, carry significant risks including anxiety, depression, and reduced functional independence. When residents modify their behavior to avoid triggering alarms, the device has effectively restricted their freedom of movement—the definition of a restraint. This requires careful evaluation of whether the restraint is medically necessary, whether less restrictive alternatives exist, and ongoing monitoring for negative effects.
Additional Issues Identified
The inspection revealed several other compliance concerns. Staff failed to apply an ordered hand splint for a resident with contractures, with the device missing from the room for multiple days while nurses signed documentation indicating it had been applied. One nurse admitted she signed off on administration without verifying the splint was actually in place.
Inspectors also found an inaccurate assessment when a resident's annual Minimum Data Set coded the resident as receiving anticoagulant medication during the assessment period, when medication records showed the resident received an antiplatelet medication instead—a clinically significant distinction requiring different monitoring protocols.
The activity director acknowledged she had failed to develop an activity care plan for one resident when the facility changed charting systems in August 2024, meaning the resident had no documented activity assessment or plan for seven months despite participating in facility programs.
The March 2025 inspection classified these violations as causing minimal harm or creating potential for more than minimal harm. The scope and severity ratings were increased for several findings due to previous citations during the facility's last annual survey, indicating ongoing patterns of non-compliance with federal care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest Hill Nursing Center from 2025-03-13 including all violations, facility responses, and corrective action plans.
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