CRYSTAL SPRINGS, MS - Federal inspectors documented a troubling pattern of infection control violations at Copiah Living Center during a May 2025 survey, with staff members observed storing gloves in their pockets, skipping hand hygiene, and handling clean supplies with feces-contaminated gloves—the same deficient practices cited during the facility's previous annual inspection.
Infection Control Lapses Place Residents at Risk
The May 8, 2025 recertification survey at the 806 West Georgetown Street facility revealed systemic failures in basic infection prevention protocols during the provision of perineal care to incontinent residents. Surveyors observed certified nursing assistants committing multiple infection control breaches while caring for two cognitively impaired residents, both of whom were documented as having severely impaired mental status and unable to advocate for themselves.
The violations were significant enough that federal regulators increased the scope and severity rating to "E," indicating a pattern of deficient practice affecting multiple residents. The facility's Director of Nursing confirmed during an interview on May 8, 2025, that the facility had been cited for identical deficient practices on its previous survey.
When asked about the repeat citations, the Nursing Home Administrator acknowledged awareness of the prior violations and attributed the recurring problems to staffing challenges. She explained that "the facility has new staff, and part-time staff could have played a part in the repeat citations."
Documented Care Failures: Resident #20
The first observation occurred on May 5, 2025, at approximately 1:55 PM, when surveyors witnessed two certified nursing assistants providing perineal care to Resident #20, a long-term resident admitted to the facility in January 2021 with a diagnosis of hypertension.
According to the inspection report, CNA #3 was observed removing gloves from her pocket and putting them on without first performing hand hygiene. She then handed a pair of gloves to CNA #1, who also applied them without washing her hands. This practice of storing gloves in pockets violates the facility's own infection prevention policies and introduces potential contaminants to supposedly clean personal protective equipment.
The resident was visibly soiled with feces when care began. During the cleaning process, CNA #3 moved from contaminated areas to clean areas of the resident's body without changing her gloves or washing her hands—a fundamental breach of infection control principles designed to prevent the spread of harmful bacteria.
Perhaps most concerning, the nursing assistant demonstrated awareness that her actions were inappropriate. According to the inspection report, "She verbalized awareness by stating she should have changed gloves and performed hand hygiene, but continued care without doing so." Despite this acknowledgment, she proceeded to apply a clean incontinence brief while still wearing feces-soiled gloves and twice removed fresh perineal wipes from their package using contaminated hands.
During a follow-up interview on May 5, 2025, CNA #3 acknowledged multiple failures in her care delivery. She admitted she should not have stored gloves in her pocket, should not have removed wipes from the pack with soiled gloves, and should have washed her hands before and during care provision. Significantly, she acknowledged that "the resident could develop a urinary tract infection as a result" of the improper care.
CNA #1 was interviewed the following day and confirmed she had applied gloves taken directly from her coworker's pocket without performing hand hygiene. She acknowledged this represented an infection control issue and stated that gloves should not be stored in pockets and hand hygiene should be performed prior to donning gloves.
Second Observation Reveals Similar Deficiencies
Two days later, on May 7, 2025, surveyors documented nearly identical infection control failures during care provided to Resident #38, a resident admitted in April 2024 with a diagnosis of dementia. This resident was also documented as having severely impaired cognitive skills for daily decision-making, meaning she could not recognize or report inadequate care.
During the 1:20 PM observation, CNA #2 was seen touching the bed remote control with her gloved hands before beginning perineal care. She then proceeded to clean feces from the resident and, while wearing those same soiled gloves, reached into the wipe package to retrieve additional supplies—contaminating the remaining wipes in the process.
When interviewed approximately one hour later, CNA #2 acknowledged her actions were incorrect and confirmed that retrieving wipes with soiled gloves could contribute to both infection and skin breakdown.
The Medical Significance of Proper Perineal Care
The infection control failures documented at Copiah Living Center carry significant medical implications for the affected residents and potentially for others in the facility. Proper perineal care and hand hygiene are not merely procedural requirements—they represent critical barriers against the transmission of dangerous pathogens.
Urinary tract infections (UTIs) are among the most common infections in nursing home residents, and improper perineal care is a well-established contributing factor. The bacteria most commonly responsible for UTIs, including Escherichia coli and other fecal organisms, can be readily introduced to the urinary tract when care providers fail to maintain proper hygiene protocols.
For elderly nursing home residents, particularly those with cognitive impairment, UTIs present elevated risks. These infections frequently present with atypical symptoms in older adults, including confusion, agitation, falls, and decreased appetite—symptoms that may be attributed to underlying dementia rather than recognized as signs of infection. This can delay diagnosis and treatment, allowing infections to progress to more serious conditions including urosepsis, a potentially life-threatening bloodstream infection.
The practice of storing gloves in pockets, as documented during both observations, defeats the purpose of wearing gloves entirely. Pockets harbor bacteria, lint, and other contaminants that transfer to the gloves. When staff members then use these pre-contaminated gloves for resident care, they may actually introduce pathogens rather than providing protection.
Similarly, the failure to change gloves when moving from soiled to clean body areas allows for cross-contamination. Fecal bacteria can be transferred to the urethral area, significantly increasing infection risk. The contamination of wipe packages with soiled gloves creates an ongoing hazard, as subsequent wipes drawn from that package will carry bacterial contamination even if used with proper technique.
What Should Have Occurred
The facility's own policies, reviewed during the inspection, clearly outline appropriate infection prevention practices. The Hand Hygiene policy, revised in January 2024, specifies that hand hygiene should be performed "between all contact with residents," "before and after procedures," "before and after applying gloves," and "when hands are visibly soiled."
According to standard nursing protocols, proper perineal care should proceed as follows: Staff should wash hands thoroughly before entering the resident's room, then don clean gloves from an appropriate dispenser or box—never from pockets. During care, staff should work from clean areas to soiled areas, change gloves immediately if they become contaminated, and perform hand hygiene before applying new gloves. Clean supplies should never be touched with soiled gloves, and all contaminated materials should be disposed of properly before touching clean items.
The facility's Infection Prevention and Control Program policy, revised in August 2021, states that the facility "has developed and maintains an infection prevention and control program that provides a safe, sanitary and comfortable environment to help prevent the development and transmission of infection." The observed practices documented during the May 2025 survey demonstrate a significant gap between written policy and actual implementation.
Staff and Leadership Response
The Licensed Practical Nurse serving as the facility's Infection Preventionist was interviewed on May 7, 2025, and confirmed the expected standards of care. She stated that hand hygiene should be performed before starting care and that gloves should never be stored in pockets. She acknowledged that CNA #2 should not have touched the bed remote or pulled wipes from the package with soiled gloves.
Importantly, the Infection Preventionist confirmed that both Resident #20 and Resident #38 "were at risk of developing urinary tract infections or other complications from improper care."
The Director of Nursing, interviewed on May 7, 2025, confirmed that CNAs are expected to wash hands prior to providing care and should not store gloves in pockets. She acknowledged that the improper perineal care observed "placed residents at risk for infection and skin breakdown."
Pattern of Non-Compliance
The repeat nature of these citations raises questions about the effectiveness of the facility's quality assurance and staff training programs. When a facility is cited for deficient practices, it is required to submit a plan of correction detailing how it will prevent recurrence. The fact that identical violations were documented on consecutive annual surveys suggests that corrective measures were either inadequate or not consistently implemented.
The facility was also cited under F867, related to quality assurance and performance improvement, with the finding that the previous annual survey citations had recurred. This citation carried a finding of "minimal harm or potential for actual harm" affecting "some" residents.
Additional Issues Identified
Beyond the infection control violations, the survey findings indicate broader concerns about the facility's ability to ensure appropriate care for incontinent residents. The inspection specifically noted failures to ensure incontinent residents received appropriate care and services to prevent the possibility of urinary tract infection, with 100 percent of residents reviewed for perineal care found to have received inadequate services.
Both affected residents were documented as having severely impaired cognitive function—Resident #20 scored a 5 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment, while Resident #38 required staff assessment for mental status and was documented as having severely impaired cognitive skills for daily decision-making. These residents represent a particularly vulnerable population who depend entirely on staff to provide appropriate, hygienic care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Copiah Living Center from 2025-05-08 including all violations, facility responses, and corrective action plans.
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