Holly Springs Rehabilitation And Healthcare Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the transport van which allowed the residents to be able to make it to their appointments. She stated she did not know the reason for the credit card not having funds and was informed that the Administrator and corporate office were aware.An interview with the DON on 11/24/25 at 10:40 AM revealed she confirmed that between the end of October and the first week of November, Resident #2, #3, and #4 missed their scheduled appointments related to no gas in the van and no funds on the company card to put gas in the van for transport. She confirmed there would have been more, but she personally filled the van once and so did the BOM so the residents could be transported to their appointments. She stated the Administrator and corporate office were aware of the issue and it was discussed daily in stand-up.An interview with the Administrator on 11/24/25 at 10:45 AM revealed he confirmed there had been an issue with the company gas card but stated it was corrected now. He denied that the van was ever out of gas, stating he filled it up himself. He then stated he did not approve any appointments to be rescheduled due to van transport card issues.An interview with the BOM on 11/24/25 at 11:00 AM revealed she confirmed that a few residents missed their scheduled appointments related to there being no funds on the company gas card. She stated that she immediately made the corporate office and the Administrator aware of the issues with the credit card. She stated this went on for about two weeks and that she put gas in the van once because she did not want residents to miss their appointments.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Holly Springs Rehabilitation and Healthcare Center

1315 Highway 4 East Holly Springs, MS 38635

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

treatment note for Resident #1 dated 10/6/25 revealed the Reason for Visit was aspiration. Diagnoses included aspiration into airway and rhonchi in both lung bases. Medication changes included beginning Albuterol Hydrofluoroalkane inhaler and amoxicillin-clavulanate.Record review of the Order Summary Report for Resident #1 revealed an order for amoxicillin-clavulanate oral suspension, 7.3 milliliters (mL) via (by) PEG-tube two times daily for upper respiratory infection (URI), and Albuterol-Budesonide inhalation aerosol 90-80 MCG/ACT (micrograms per actuation), two puffs orally every four hours as needed for shortness of breath/wheezing.A continued review of the resident's record with the Minimum Data Set (MDS) Nurse on 11/24/25 at 11:20 AM revealed she could find no increase in monitoring for Resident #1 related to his continuous episodes of going into other residents' rooms and taking food.An interview with

the Director of Nursing on 11/24/25 at 11:55 AM revealed Resident #1 was NPO and had a PEG tube for nutrition. She stated he had been to the hospital multiple times related to getting food from wherever. She stated it was difficult to alter this behavior because the resident was mobile in his wheelchair and, if he smelled food, he was going after it. She stated he was on every-shift visual monitoring for wandering behaviors but confirmed the facility had not increased monitoring despite the increase in episodes of taking food and requiring ED transfers for signs of aspiration. She stated, We took the snacks from the desk, but if

he wants it, he is going to find it. She stated the facility had been attempting placement in another facility due to his need for increased monitoring and care, but no one would accept him. She confirmed she asked administration about placing the resident on one-on-one supervision, but this never occurred. She confirmed the resident remained at risk for taking others' food and for aspiration.An interview with the Social Worker (SW) on 11/24/25 at 12:45 PM revealed she had sent numerous referrals to other facilities due to Resident #1's need for extra monitoring and care, but no facility would accept him. She confirmed that with the resident's continued attempts to obtain food, the facility should have increased his monitoring until other solutions could be found.An interview with Certified Nurse Assistant (CNA) #1 on 11/24/25 at 12:10 PM revealed she cared for Resident #1 when he lived at the facility. She stated she was not aware of any increased monitoring of the resident. She stated they tried to keep a good eye on him, but he could propel himself and we all have other duties as well.An interview with Licensed Practical Nurse (LPN) #1 on 11/24/25 at 12:15 PM revealed she cared for Resident #1 when he was a resident. She stated the resident continuously tried to go into other residents' rooms. She confirmed she attempted to redirect him but stated

this often did not work. She stated, to her knowledge, the facility never increased his monitoring to prevent him from going into other residents' rooms seeking food.An interview with the Assistant Director of Nursing

on 11/24/25 at 1:00 PM revealed she was aware of Resident #1's behavior of going into other residents' rooms and obtaining food. She stated placing the resident on one-on-one supervision had been discussed, but it was not in the budget, and with other staffing concerns, no one wanted to come in and do it.Record

review revealed that the family discharged the resident from the facility on 11/06/25 prior to the State Agency entrance.

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