F-F690
, .Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an incontinent resident received appropriate care and services to prevent
the possibility of a urinary tract infection . and for
F-F690
, .Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an incontinent resident received appropriate care and services to prevent
the possibility of a urinary tract infection . and for
F-F880
, .Based on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection .
During the current recertification survey, the facility failed to ensure incontinent residents received appropriate care and services to prevent the possibility of urinary tract infection for two (2) of two (2) residents reviewed for perineal care and failed to follow infection control practices during the provision of perineal care for two (2) of two (2) residents observed for perineal care.
On 5/8/25 at 11:47 AM, during an interview with the Director of Nursing (DON), she confirmed the facility was cited for the same deficient practices on the previous survey that was identified during the current survey.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 255291 Department of Health & Human Services Printed: 08/27/2025 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 255291 B. Wing 05/08/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Copiah Living Center 806 West Georgetown Street Crystal Springs, MS 39059
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 On 05/08/25 at 2:00PM, in an interview, the Nursing Home Administrator (NHA) explained that she is aware of the previous annual survey citations, and the facility has new staff, and part-time staff could have played a Level of Harm - Minimal harm or part in the repeat citations. potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 255291 Department of Health & Human Services Printed: 08/27/2025 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 255291 B. Wing 05/08/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Copiah Living Center 806 West Georgetown Street Crystal Springs, MS 39059
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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41680 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to follow infection Residents Affected - Some control practices during the provision of perineal care for two (2) of two (2) residents observed for perineal care, Resident #20 and Resident #38, as evidenced by not performing hand hygiene, using gloves inappropriately stored in pockets, continuing care with soiled gloves, and retrieving wipes from the packet with contaminated gloves, placing residents at risk for cross-contamination and infection.
This deficiency was also cited on the last Recertification Survey, therefore the scope/severity was increased to E representing a pattern.
Findings included:
A review of the facility's policy, Infection Prevention and Control Program, revised 8/21, revealed, This 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 .
A review of the facility's policy, Hand Hygiene, revised 1/24, revealed, .Cleanse hands to prevent transmission of infection or other conditions . Indications for Hand Washing .2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room [ROOM NUMBER]. Before and after procedures. 4. Before and after applying gloves. 5. When hands are visibly soiled .Selecting Hand Washing Method .2. When to wash with soap and water .d. When hands are visibly contaminated with blood or bodily fluids .
Resident #20
A record review of Resident #20's Admission Record revealed the facility admitted the resident on 1/11/21 with diagnoses including Hypertension.
A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident's cognition was severely impaired.
On 5/5/25 at 1:55 PM, during an observation of perineal care for Resident #20, Certified Nursing Assistant (CNA) #3, assisted by CNA #1, was observed removing gloves from her pocket and applying them without first performing hand hygiene. CNA #3 also handed a pair of gloves to CNA #1, who applied them without washing her hands. CNA #3 then began providing care to Resident #20, who was visibly soiled with feces.
During care, CNA #3 moved from dirty to clean areas without removing gloves or washing her hands. She verbalized awareness by stating she should have changed gloves and performed hand hygiene, but continued care without doing so. CNA #3 applied a clean brief while wearing soiled gloves and was observed removing perineal wipes from the package twice with contaminated gloves.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 255291 Department of Health & Human Services Printed: 08/27/2025 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 255291 B. Wing 05/08/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Copiah Living Center 806 West Georgetown Street Crystal Springs, MS 39059
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 5/5/25 at 2:14 PM, during an interview with CNA #3, she acknowledged she should not have stored gloves in her pocket or removed wipes from the pack with soiled gloves. She admitted she should have Level of Harm - Minimal harm or washed her hands before beginning care and during care. She acknowledged she had not provided proper potential for actual harm perineal care and stated that the resident could develop a urinary tract infection as a result.
Residents Affected - Some On 5/6/25 at 1:18 PM, during an interview with CNA #1, she confirmed she applied gloves taken from CNA #3's pocket without washing her hands. She acknowledged this was an infection control issue and that gloves should not be stored in pockets, and hand hygiene should be performed prior to donning gloves.
Resident #38
A record review of Resident #38's Admission Record revealed the facility admitted the resident on 4/5/24 with diagnoses including Dementia.
A record review of the Quarterly MDS with an ARD of 4/18/25 revealed the resident required a staff assessment for mental status and was documented as having severely impaired cognitive skills for daily decision making.
On 5/7/25 at 1:20 PM, during an observation of perineal care for Resident #38, CNA #2 was observed touching the bed remote control with gloved hands prior to starting care. She continued care by cleaning feces from the resident and removed additional wipes from the package using soiled gloves.
On 5/7/25 at 2:13 PM, during an interview with CNA #2, she acknowledged her actions during care were incorrect. She confirmed that retrieving wipes with soiled gloves could contribute to infection and skin breakdown.
On 5/7/25 at 3:50 PM, during an interview with the Licensed Practical Nurse (LPN)/Infection Preventionist,
she confirmed that hand hygiene should be performed before starting care and gloves should never be stored in pockets. She stated CNA #2 should not have touched the bed remote or pulled wipes from the package with soiled gloves. She acknowledged that both Resident #20 and Resident #38 were at risk of developing urinary tract infections or other complications from improper care.
On 5/7/25 at 4:00 PM, during an interview with the Director of Nursing (DON), she confirmed 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.
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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 255291