F-F725
Findings include:
Review of facility policy titled, Bath, Shower/Tub revised 8/25/14 revealed, .Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .
Review of facility policy titled, Fingernails/Toenails, Care of revised date 2/18 revealed, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .
Resident #8
On 5/19/25 at 6:43 PM during an observation and interview with Resident #8, it was revealed that the resident was lying in bed wearing a white t-shirt, and his fingernails were one-half inch (1/2) long with a brown substance underneath and jagged edges. The resident confirmed that he preferred his nails to be trimmed short and kept clean.
On 5/20/25 at 3:20 PM an observation and interview with Certified Nursing Assistant (CNA) #1 confirmed that Resident #8 had long, dirty fingernails with a brown substance underneath. She revealed that nails were supposed to be cleaned and trimmed on shower days, and that Resident #8's shower days were Monday, Wednesday, and Friday (M/W/F). She further mentioned that due to a staffing shortage yesterday (5/19/25), that Resident #8 did not receive his shower during the day shift. An observation revealed that Resident #8 was wearing the same clothing today as he did yesterday. CNA #1 confirmed that Resident #8 could develop
an infection in his nails or could suffer a skin tear or even a staph infection due to the current condition of his nails.
An observation and interview on 5/20/25 at 3:25 PM with Resident #8, it was revealed that the resident was lying in bed wearing the same white t-shirt, which was now covered with food stains and the resident confirmed he had not had a shower since Friday, 5/16/25.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 255212 Department of Health & Human Services Printed: 08/26/2025 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 255212 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyards Comm Living Center 907 East Walker Street Fulton, MS 38843
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 0677 During an interview on 5/20/25 at 3:45 PM with the Director of Nursing (DON), she confirmed that nails should be cleaned and trimmed at least weekly and as needed (PRN). She further confirmed that long, dirty Level of Harm - Minimal harm or nails with jagged edges could cause a skin tear and could lead to infection. potential for actual harm
A record review of Resident #8's Admission Record revealed he was admitted to the facility on [DATE REDACTED], with Residents Affected - Some diagnoses that included Unspecified Sequelae of Cerebral Infarction, Type II Diabetes Mellitus with other Diabetic Kidney Complication, and Need for Assistance with Personal Care.
A record review of Resident #8's Minimum Data Set (MDS) revealed an Assessment Reference Date (ARD) of 4/1/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated that
he had moderate cognitive impairment.
Resident #53
On 5/19/25 at 6:30 PM during an observation and interview with Resident #53, it was revealed that he had one-fourth inch (1/4) facial hair and a mild odor. The resident stated his shower days were M/W/F, but he did not receive his shower today. He verbalized, I guess they don't have enough girls working today. Resident #53 confirmed that they normally shaved him while he's in the shower and that he preferred to be clean-shaven. He further stated, I hope no one has to get close to me today because I haven't had a shower since Friday.
On 5/20/25 at 3:02 PM during an interview with CNA #3, it was revealed that on M/W/F, the odd-numbered rooms received showers and on Tuesday, Thursday, Saturday (T/Th/S), the even-numbered rooms received showers. She revealed that yesterday, 5/19/25, a CNA called in, and they pulled one of the CNAs from the shower team to cover the call-in, which left only one CNA to do showers. CNA #3 revealed that when that happens, the shower aide only gives showers to rooms one through ten during the day shift and rooms eleven through twenty-one were supposed to receive showers during the night shift. CNA #3 further confirmed that linens were normally changed on shower days and revealed that if the residents didn't receive showers on those scheduled days, their linens were not changed either.
During an interview on 5/20/25 at 3:05 PM with CNA #1, she confirmed that Resident #53 did not receive his scheduled shower yesterday.
During an interview on 5/20/25 at 3:46 PM with the DON, it was confirmed that staffing was a problem, especially over the last two weeks.
A record review of Resident #53's Admission Record revealed that the resident was admitted to the facility
on [DATE REDACTED], with diagnoses that included Unspecified Dementia, Unspecified Lack of Coordination, and Muscle Weakness.
A record review of Resident #53's MDS revealed an ARD of 4/17/25, and in Section C, a BIMS score of 14, which indicated that the resident was cognitively intact.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 255212 Department of Health & Human Services Printed: 08/26/2025 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 255212 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyards Comm Living Center 907 East Walker Street Fulton, MS 38843
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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48845
Residents Affected - Some Based on observation, interview, record review, and policy review, the facility failed to ensure sufficient nursing staff were available to meet the Activities of Daily Living (ADL) needs of dependent residents, as required by the residents' care plans and the facility's staffing policy. This failure resulted in two (2) of 61 sampled residents (Resident #8 and Resident #53) not receiving scheduled showers, hygiene care, and nail care.
Findings include:
Review of facility's policy titled, Staffing with review date 10/22 revealed, Policy Statement Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .
Record review of the Payroll Based Journal Staffing Data Report for Fiscal Year Quarter 1 2025 (October 1 - December 31), revealed, Excessively Low Weekend Staffing Triggered = Weekend Staffing data is excessively low.
During an observation and interview on 5/19/25 at 6:30 PM with Resident #53 revealed one-fourth inch (1/4) facial hair and mild body odor. Resident #53 stated his shower days were Monday/Wednesday/Friday (M/W/F), but he did not receive his shower today. He verbalized, I guess they don't have enough girls working today. Resident #53 confirmed they normally shaved him while he's in the shower and he preferred to be clean shaven. He also revealed that they normally changed his sheets too, but that had not been done either. Resident #53 further stated, I hope no one has to get close to me today because I haven't had a shower since Friday.
A record review of Resident #53's Admission Record revealed that the resident was admitted to the facility
on [DATE REDACTED], with diagnoses that included Unspecified Dementia, Unspecified Lack of Coordination, and Muscle Weakness.
A record review of Resident #53's MDS revealed an ARD of 4/17/25, and in Section C, a BIMS score of 14, which indicated that the resident was cognitively intact.
An observation and interview on 5/20/25 at 3:20 PM with CNA #1 confirmed that Resident #8 had long, dirty fingernails with a brown substance underneath. She revealed that nails were supposed to be cleaned and trimmed on shower days, and that Resident #8's shower day was M/W/F. She further revealed that due to a staffing shortage yesterday (5/19/25) that Resident #8 did not receive his shower on day shift. Resident #8 stated he had not had a shower since 05/16/25. An observation revealed that Resident #8 had the same clothing on today as he did yesterday and now his shirt had food stains throughout the front of it.
A record review of Resident #8's Admission Record revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included Unspecified Sequelae of Cerebral Infarction, Type II Diabetes Mellitus with other Diabetic Kidney Complication, and Need for Assistance with Personal Care.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 255212 Department of Health & Human Services Printed: 08/26/2025 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 255212 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyards Comm Living Center 907 East Walker Street Fulton, MS 38843
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 0725 A record review of Resident #8's MDS revealed an Assessment Reference Date (ARD) of 4/1/25 and, in Section C, a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate Level of Harm - Minimal harm or cognitive impairment. potential for actual harm
During an interview with Certified Nursing Assistant (CNA) #3 on 5/20/25 at 3:02 PM, she stated there had Residents Affected - Some been a call-in the previous day, which caused them to have to pull a shower aide to cover floor duties. She further verbalized that when such situations arise, the remaining shower aide was responsible for providing showers to residents in rooms 1 through 10, while the night shift staff was tasked with handling the remaining residents. CNA #3 confirmed that this staffing issue sometimes resulted in residents not receiving their showers on their scheduled shower days and not getting their bed linens changed. She confirmed that bed linens were supposed to be changed routinely on shower days.
During an interview on 5/20/25 at 3:46 PM, with the Director of Nursing (DON), revealed that the facility has been actively seeking to fill these open positions by utilizing platforms on social media, as well as hosting job fairs. Despite these efforts, she expressed difficulty in attracting and retaining qualified staff.
An interview on 5/21/25 at 9:08 AM with Registered Nurse (RN) #1, she revealed that she recently moved to
the floor from Minimum Data Set (MDS) Nurse due to staffing problems. She confirmed that the facility had been struggling with staffing recently and stated, We struggle a little bit, but we make do. RN #1 verbalized that the facility had participated in several job fairs, posted openings on social media, handed out flyers to local businesses and churches, etc. She further revealed that corporate held a job fair recently and had no nursing or CNA applicants/prospects to show up. RN #1 stated, to say we are struggling is putting it mildly.
She confirmed the pay scale for CNAs was low there and they were the backbone of the facility.
An interview on 5/21/25 at 9:19 AM with CNA #4 (shower aide) she revealed that she was pulled from the shower team to work the floor often due to staff call ins, which meant residents would miss their shower days. She confirmed that this leaves only one (1) shower aide for the entire building which sometimes caused showers and other things to be missed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 255212 Department of Health & Human Services Printed: 08/26/2025 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 255212 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyards Comm Living Center 907 East Walker Street Fulton, MS 38843
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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48845 Residents Affected - Few Based on observation, resident and staff interview, record review and facility policy review, the facility failed to safely store medications two (2) of (5) five residents medications observed. (Resident #5 and #56)
Findings include:
Record review of facility policy titled, Medications, Individual Medication Storage Cabinets dated 8/25/14, revealed, Medication administration utilizing individual medication storage cabinets will meet the same criteria for timeliness, infection control, and medication safety as standard medication administration.
Resident #5
On 5/20/25 at 8:42 AM, an observation and interview with Resident #5 revealed a Simethicone Capsule 125 milligram (MG) sitting in a medicine cup on her bedside table. Resident #5 confirmed that the capsule was her stomach medication, which the nurse had left for her to take later today.
On 5/20/25 at 8:45 AM, an interview with the Licensed Practical Nurse (LPN) #1 confirmed that she had left medication in a medicine cup for Resident #5 on her bedside table for her to take later. She acknowledged that this practice was inappropriate, as it posed a risk that another resident could mistakenly take the medication.
A record review of Resident #5's Order Summary Report dated 5/20/25, revealed, .Simethicone Capsule 125 MG Give one (1) capsule by mouth three times a day for bloating, gas .
On 5/22/25 at 9:00 AM, an interview with the Director of Nursing (DON) confirmed that medication should never be left at the bedside for a resident to take later. She stated that this practice puts other residents at risk because anyone could come into the room and take the medication that was not prescribed for them, or
the resident could wait too late to take it and she has another dose upcoming at noon.
A record review of Resident #5's Admission Record revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included Unspecified Dementia.
A record review of Resident #5's Minimum Data Set (MDS) revealed an Assessment Reference Date (ARD) of 4/1/25 under Section C, a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment.
41878
Resident #56
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 255212 Department of Health & Human Services Printed: 08/26/2025 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 255212 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyards Comm Living Center 907 East Walker Street Fulton, MS 38843
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 0761 During an observation of the medication administration pass for Resident #56 on 5/20/25 at 10:30 AM, LPN #1 prepared medications for administration. The resident had an order for Potassium Chloride Liquid 20 Level of Harm - Minimal harm or MEQ (milliequivalent) per 15 ml (milliliters) give 10 MEQ by mouth - Directions mix 7.5 ml (10 MEQ) in 120 potential for actual harm ml of water and give by mouth one time a day. LPN #1 mixed the Potassium Chloride Liquid into 120 ml of thickened water and took this with the other medications into the resident's room. The resident drank part of Residents Affected - Few the medication/water mixture and did not want the remainder, and the nurse told her she would leave it at the bedside, and she would try again later. LPN #1 left the room with the medication on the resident's overbed table and pushed the medication cart down the hall to the next resident's room. When asked about leaving
the medication at bedside, LPN #1 acknowledged it was not safe to leave medications unattended since another resident could take it. She acknowledged that potassium was a medication that could be dangerous for a resident not needing extra potassium and should not have been left at bedside. She then went into the room and discarded the medication. She confirmed she had been in-serviced on not leaving medication at bedside.
An interview with the facility's Pharmacist on 5/20/25 at 10:40 AM, revealed the facility nurses are not to leave medication unattended at a resident's bedside and this was discussed during the most recent in-service.
During an interview on 5/21/25 at 10:10 AM, the Director of Nursing acknowledged that for the safety of the residents as well as other people in the facility, medications should be stored properly and should not be left unattended at the bedside. She stated another resident could have taken the medication which could have led to health problems for them, especially with potassium. She confirmed the facility failed to properly store medications.
Record review of in-service by the DON and Pharmacist titled, Med Pass - General dated 4/10/25, revealed LPN #1's signature on the sign-in sheet which indicated she attended the training. The in-service consisted of Med Pass Points which included, Meds are never to be left at the bedside for the resident to take later.
Record review of Resident #56's Order Summary Report revealed an order dated 12/2/24 for Potassium Chloride Liquid 20 MEQ per 15 ml (10%) - give 10 MEQ by mouth one time a day related to Hypokalemia. Directions: Mix 7.5 ml (10 MEQ) in 120 ml of water and give by mouth one time a day.
Record review of Resident #56's Admission Record revealed she was admitted by the facility on 8/7/24. Her diagnoses included Alzheimer's Disease and Chronic Kidney Disease.
Record review of Resident #56's MDS with ARD of 4/17/25 revealed the resident had a BIMS score of three (3) which indicated the resident had severe cognitive impairment.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 255212 Department of Health & Human Services Printed: 08/26/2025 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 255212 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyards Comm Living Center 907 East Walker Street Fulton, MS 38843
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** 41878 potential for actual harm Based on observation, resident and staff interview, record review, and facility policy review, the facility failed Residents Affected - Few to utilize standard precautions with glove use during medication administration for Resident #35 and failed to use Enhanced Barrier Precautions (EBP) during catheter care for Resident #55 for two (2) of six (6) resident care areas observed.
The scope for F 880 was increased to E due to a prior citation on the last annual recertification survey on 2/20/24, which represents a pattern of deficiency.
Findings include:
Record review of facility policy titled, Medication Administration - General Guidelines dated 8/25/14, revealed, .Hand hygiene is performed and gloves are used in accordance with standard precautions for medication administration .
Record review of facility policy titled, Infection Prevention and Control Program Overview, dated 10/6/17, revealed, The goals of the infection prevention and control program are to: A. decrease the risk of infection to residents and personnel .
Resident #35
During observation of the medication administration pass for Resident #35 on 5/20/25 at 10:10 AM, Licensed Practical Nurse (LPN) #1 prepared medications for administration. The resident had an order for Vitamin B12 250 micrograms (mcg) and a 500 mcg Vitamin B12 was available. LPN #1 used the pill splitter to half the tablet. She placed her ungloved finger on half of the tablet to hold it in the pill splitter, and she dropped the other half into the resident's medication cup. She then picked up the other half of tablet in the pill splitter with her bare finger and placed it back into the medication bottle. During an interview with LPN #1, she confirmed for infection control purposes, she should have disposed of the tablet or worn gloves so her bare hands would not contaminate the medications in the bottle. She stated she had been in-serviced on infection control
during medication pass.
During an interview on 5/20/25 at 10:40 AM, the facility's Pharmacist stated the facility's nursing staff had been in-serviced on infection control during medication administration.
During an interview on 5/21/25 at 10:10 AM, the Director of Nursing (DON) revealed infection control measures were to be used during medication administration. She confirmed the facility failed to ensure safe practices were used to decrease the likelihood of the spread of infection by placing a medication that had been in the nurse's ungloved hands back into the medication bottle.
Record review of in-service by the DON and pharmacist titled, Med Pass - General dated 4/10/25, revealed LPN #1's signature on the sign-in sheet which indicated she attended the training. The in-service consisted of Med Pass Points which included, Infection Control . Never touch any medication with your bare hands.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 255212 Department of Health & Human Services Printed: 08/26/2025 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 255212 B. Wing 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Courtyards Comm Living Center 907 East Walker Street Fulton, MS 38843
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 Record review of Resident #35's Order Summary Report revealed an order dated 2/27/25 for Cyanocobalamin Tablet 250 micrograms by mouth daily for B12 deficiency. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #35's Admission Record revealed she was admitted to the facility on [DATE REDACTED], with diagnoses that included Alzheimer's Disease, Hypertension, and Osteoporosis. Residents Affected - Few
Record review of Resident #35's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/1/25 revealed a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident had
a severe cognitive impairment.
48845
Resident #55
Review of facility policy titled, Enhanced Barrier Precautions with no date revealed, Policy Statement Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EPBs include: .g. device care .urinary catheter .
During an observation on 5/21/25 at 9:28 AM of catheter care for Resident # 55 with Certified Nursing Assistants (CNAs) #1 and #2, it was revealed that both CNAs failed to use Enhanced Barrier Precautions (EBP) during catheter care.
On 5/21/25 at 9:36 AM, an interview with CNAs #1 and #2 revealed that neither CNA was aware that EBP should have been used during catheter care. CNA #1 stated that EBP are used to prevent the spread of infection between the resident and staff and/or from resident to resident. Additionally, she confirmed that not adhering to the EPB could cause an infection for Resident #55.
On 5/21/25 at 9:54 AM, an interview with the DON confirmed that EBP should have been used during catheter care and that the CNAs were trained to do so. She verbalized that EBP were put into place to help prevent the spread of infection and failing to utilize EBP could place Resident #55 at an increased risk for infection.
Record review of Order Summary Report for Resident #55 dated 5/21/25, revealed, .Catheter care using soap and warm water or wipes every shift .
Record review of Admission Record for Resident #55 revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses which included Neuromuscular Dysfunction of Bladder.
A record review of Resident #55's MDS with an ARD of 3/1/25, and in Section C, Resident #55 has a BIMS score of 13 which indicates that the resident is cognitively intact.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 255212