Lawrence Co Nursing Center

F-F851 - Payroll-Based Journal Reporting

During this recertification survey, the provider failed to ensure their Payroll Based Journal (PBJ)-which documents staffing hours required to provide appropriate care to residents-was corrected before submission to the Centers for Medicare & Medicaid Services (CMS) for one (1) of four (4) quarters in 2024.

During the recertification survey in February 2024, the provider failed to ensure PBJ reporting was corrected

before submission to CMS for one (1) of four (4) quarters in 2023.

F-F880 - Infection Prevention and Control

During this recertification survey, the facility failed to prevent the possible spread of infection by not exercising proper hand hygiene during perineal care for two (2) of three (3) residents observed.

During the recertification survey in February 2024, the facility failed to prevent the possible spread of infection by not exercising proper hand hygiene during perineal care for one (1) of fifteen (15) sampled residents observed.

On 04/02/25 at 2:27 PM, in an interview with the Director of Nursing (DON), she confirmed that the facility had been cited for the same infection control issue during the previous year's survey. She explained that it is not due to a lack of inservice training but stated they may need to rethink their approach. She suggested implementing more supervision while staff are providing care. She added that although high-risk meetings are held, they do not address infection control tasks like this.

On 04/02/25 at 2:31 PM, during an interview with the Staffing Coordinator, she acknowledged that the facility had been cited for the same infection control issues. She stated that while inservices are provided, she believes the frequency of training on hand hygiene and glove use should be increased.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 255214 Department of Health & Human Services Printed: 08/31/2025 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 255214 B. Wing 04/02/2025

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

Lawrence CO Nursing Center 700 Jefferson Street South Monticello, MS 39654

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 0865 On 04/02/25 at 2:45 PM, in an interview with the Administrator, he stated that recurring infection control issues are largely due to the need for increased staff monitoring. The Administrator confirmed there were Level of Harm - Minimal harm or errors in PBJ reporting during the prior recertification survey. He stated that the issue persists due to a recent potential for actual harm upgrade to their time clock system. He suggested there may be a transmission problem between the time clock and the PBJ reporting system. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 255214 Department of Health & Human Services Printed: 08/31/2025 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 255214 B. Wing 04/02/2025

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

Lawrence CO Nursing Center 700 Jefferson Street South Monticello, MS 39654

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** 50751 potential for actual harm Based on observation, interview, record review, and policy review, the facility failed to follow proper infection Residents Affected - Some control guidelines for two (2) of three (3) care observations. Resident# 5 and Resident #44.

Findings include:

Record review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 03/24 revealed . Enhanced Barrier Precautions are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO (Multidrug Resistant Organisms) .

Record review of the facility policy titled Hand Hygiene revised 08/14/24 revealed .2. Hand hygiene should be performed between all contact with residents, or when entering and exiting a resident ' s room .4. before and after applying gloves, 5. when hands are visibly soiled 9. Wearing gloves does not replace the need to perform hand hygiene

Resident #5

On 04/01/25 at 10:18 AM, Resident #5 was observed during wound care to the sacral area. At this time, Licensed Practical Nurse (LPN) #3 and Certified Nursing Assistant (CNA) #2 were present and performing

the wound care. Neither staff member was wearing gowns. Prior to the wound care, the resident had soiled her brief with urine. CNA #2 notified the nurse. However, wound care was observed being provided and completed prior to staff changing the resident's brief. After changing the brief, staff did not perform perineal care.

On 04/01/25 at 10:30 AM, LPN #3 verified during an interview, that she did not wear a gown. She stated the resident is on Enhanced Barrier Precautions, therefore a gown should have been worn by herself and CNA #2 during care. She also stated that perineal care should have been performed at the time the brief was changed and that the brief should have been changed before wound care was initiated to prevent infection.

On 04/01/25 at 10:32 AM, CNA #2 stated that the resident's brief should have been changed prior to performing wound care and that she should have performed perineal care prior to leaving the room, rather than just changing the brief. She acknowledged that this was necessary to prevent infection due to the resident's incontinent episode of urine. She also stated she should have worn a gown before entering the room to provide care.

Record review Admission record revealed Resident #5 was admitted on [DATE REDACTED] with a diagnoses that included Schizoaffective disorder.

Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/8/25, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section M documented a Stage 2 pressure injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 255214 Department of Health & Human Services Printed: 08/31/2025 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 255214 B. Wing 04/02/2025

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

Lawrence CO Nursing Center 700 Jefferson Street South Monticello, MS 39654

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 Order Summary Report with active orders as of 4/1/25 revealed a physician order dated 3/7/25, Cleanse Stage 2 pressure wound to the sacral area with wound cleanser, pat dry, apply Nystatin Level of Harm - Minimal harm or powder (around the peri-wound), apply Duoderm, and cover with foam dressing daily until healed. potential for actual harm Resident #44 Residents Affected - Some

On 04/01/25 at 3:30 PM, Resident #44 was observed receiving perineal care. CNA #1 provided the care.

During the process, she was observed cleaning stool from the resident using a brief. She had gloves on. She then wrapped the stool in the brief, placed it in a receptacle, and left the bedside wearing the same soiled gloves. She touched multiple surfaces, turned on the sink faucet, and applied soap to a new towel to clean

the resident, all while still wearing the soiled gloves.

On 04/02/25 at 9:25 AM, CNA #1 was interviewed and confirmed that she should have removed her soiled gloves prior to leaving the bedside to avoid possibly spreading contamination from stool to the sink and anything else she touched.

On 04/02/25 at 10:11 AM, the Director of Nursing (DON) revealed that staff should remove gloves and perform hand hygiene prior to touching anything else in the room to avoid spreading infection.

On 04/02/25 at 10:12 AM, the Infection Preventionist (LPN #1) revealed staff should remove gloves to prevent the spread of infection to other surfaces, especially when contaminated with stool.

Record review of the Admission Record revealed Resident #44 was admitted on [DATE REDACTED] with diagnoses that included Hypertensive heart disease without heart failure.

Record review of the MDS with an ARD of 2/24/25, Section H, revealed that Resident #44 is always incontinent of bowels.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 255214