Clarksdale Nursing Center

F-F677

Review of the facility policy titled QAPI Performance Improvement Project (PIP) with a revision date of 11/22 revealed, The QA Committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement through the use of a QAPI self-assessment. In addition, the QA Committee will implement any PIP topics as indicated through data analysis. PIPs are implemented in accordance with CMS' protocol for conducting PIPs, including: 1. Measurement of performance using objective quality indicators. 2. Implementation of system interventions to achieve improvement in quality based on Root Cause Analysis. 3. Evaluation of the effectiveness of the interventions. 4. Plan and initiation of activities for increasing or sustaining improvement.

An interview with the Administrator (ADM) on 08/15/24 at 10:05 AM revealed she was not aware that the resident's Activities of Daily Living (ADL) were not being done and was a concern for the facility again. She revealed after we were cited for ADLs during our annual survey last year and again cited on a complaint survey this year, the Interdisciplinary Team (IDT) discussed those in Quality Assurance Performance Improvement (QAPI), which involved our Medical Director, and we put measures in place, with monitoring to ensure this would be resolved but obviously something is wrong if this is a continued issue, and our plan is not working.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 255267 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255267 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Clarksdale Nursing Center 1120 Ritchie Ave Clarksdale, MS 38614

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 0867 Record review of the Facility's Plan of Correction (POC) dated 5/5/23 revealed under, 3. All Licensed Practical Nurses, Registered Nurses and Certified Nursing Assistants were in-serviced on the policy Nail Level of Harm - Minimal harm or Care on 04/13/23, 04/18/23 & 04/19/23 by the Director of Nursing. Orders were written for nail care and potential for actual harm placed on the Electronic Medical Administration Record (EMAR) for nurses to check and initial weekly to assure that proper nail care is being done on all residents. 4. Nail care has been added to all resident's Residents Affected - Some EMAR. Licensed Practical Nurses or Registered Nurses will assess all fingernails weekly and clean and trim as indicated. The Registered Nurse Supervisor will monitor nail care five times a week while making daily rounds. The Director of Nursing will monitor the EMAR weekly for four weeks and then monthly for two months. Monitoring began on April 7, 2023. The director of Nurses will report any concerns to the Quality Assurance Committee. The Director of Nurses or the Administrator will report any concerns to the Quality Assurance Committee weekly for four weeks and then quarterly. The Quality Assurance Committee met with

the Medical Director on April 10, 2023, post annual State Survey to review potential tags. The Medical Director will meet with the Quality Assurance Committee on May 2, 2023 to review/approve the Plan of Correction for the actual tags. The Quality Assurance Committee will monitor quarterly for one year until the deficient practice is resolved and will make revisions and/or corrections when needed to current plan of corrections.

Record review of the Facility's Plan of Correction (POC) dated 7/2/24 revealed under, 3. All nursing staff were in-serviced on the policy Activities for Daily Living and the importance of following the residents care plans on June 26, 27, 28, 29 and July 1, 2024 by the Director of Nursing, Staff Development/Infection Preventionist and Staff Nurse. All Staff will be in-serviced four times per year and as needed on Activity of Daily Living including incontinent care, good nutrition, grooming, personal and oral hygiene by Staff Development. The Director of Nursing, Staff Development/Infection Preventionist and Nursing Supervisors will make random rounds on eight residents daily for two weeks, then two times a week for two weeks. An emergency Quality Assurance meeting on June 28, 2024 was held with the Medical Director for approval of Plan of Correction. Any problems will be placed on a Quality Improvement form and weekly in the Department Head Meeting until resolved. 4. The Administrator will report to the Quality Assurance Committee quarterly. The Quality Assurance Committee will monitor quarterly until the deficient practice is no longer an issue and will make revisions and/or corrections when needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 255267 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255267 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Clarksdale Nursing Center 1120 Ritchie Ave Clarksdale, MS 38614

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 47157 potential for actual harm Based on observation, resident and staff interview, record review, and facility policy review, the facility failed Residents Affected - Few to implement Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) for intravenous antibiotic therapy on two (2) of five (5) care area observations requiring enhanced barrier precautions. (Resident # 157).

Findings include:

A review of the facility policy titled, Enhanced Barrier Precautions, revised 03/24, revealed .Indwelling medical device examples include central lines . A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP .

During entrance rounds on 8/13/24 at 12:00 PM, an observation revealed Registered Nurse (RN)/ Treatment nurse hanging a bag of intravenous (IV) fluids to Resident #157 right upper arm access device. The RN/Treatment nurse was not observed to be wearing a gown for enhanced barrier precautions, and there were no signs observed in the resident's room or on the doorway to alert staff of enhanced barrier precautions.

Record review of the Physician Orders List revealed an order dated 7/23/24 for ceftriaxone 2-gram solution for injection: Administer 2 mg (milligrams)/100 milliliter(s) intravenous once daily until 8/18/2024. d/c (discontinue) PICC midline catheter care after last dose of IV antibiotic .

In an observation on 8/14/24 at 12:35 PM, revealed an enhanced barrier sign observed on the outside doorway to Resident #157's room. Observed the RN Supervisor enter Resident #157's room to administer ceftriaxone intravenous (IV) solution via the PICC line. The RN Supervisor was observed connecting the IV tubing to the resident's right upper arm PICC line access device. The RN Supervisor did not put on a gown for enhanced barrier precautions before the procedure. Upon exiting the room, the RN Supervisor was asked if Resident #157 was on enhanced barrier precautions. She stated yes and pointed to the enhanced barrier precaution sign on the outer doorway of Resident #157's room. She then confirmed that she did not use enhanced barrier precautions while hanging Resident 157's IV antibiotics via his PICC line.

In an interview with the Infection Control Nurse on 8/14/24 at 1:04 PM, she revealed she was unaware Resident #157 had a PICC line. She confirmed the resident should be on enhanced barrier to reduce the risk of transmission of bacteria while providing care to the PICC line device.

An interview with RN/Treatment nurse on 8/14/24 at 1:18 PM, she confirmed she hung the IV antibiotics on 8/13/24 around noon, she confirmed there was no enhanced barrier sign on the doorway on 8/13/24 and that

she did not use enhanced barrier precautions because she was unable to find a gown. She revealed she was aware that she should have followed the enhanced barrier precautions because Resident #157 had a PICC line device.

During an interview with the Resident #157 on 8/14/24 at 1:50 PM, he revealed that he has only seen staff wear a gown a couple of times to hang his IV medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 255267 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255267 B. Wing 08/15/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Clarksdale Nursing Center 1120 Ritchie Ave Clarksdale, MS 38614

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 0880 On 8/14/24 at 2:00 PM, in an interview with the Director of Nursing she confirmed staff should have been using enhanced barrier precautions while administering the IV antibiotics for Resident #157's through his Level of Harm - Minimal harm or PICC line device. potential for actual harm

Review of the Face Sheet revealed the facility admitted Resident #157 key on 7/23/24 with diagnoses that Residents Affected - Few included Osteomyelitis of vertebra, lumbar region.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 255267