Wisteria Gardens

F-F812, .Based on

observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerator, freezers, and the dry storage room were dated, labeled, and discarded by the expiration date .

During the current annual recertification survey, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to expired foods, freezer burned foods, improperly stored foods, and unlabeled and undated foods for two (2) of (2) kitchen observations.

On [DATE REDACTED] at 11:45 AM, during an interview the Administrator, stated that she was aware that on the last annual survey on [DATE REDACTED], the facility was cited for food procurement and unlabeled food items. She stated that she performed random checks of the kitchen for dates and labels several times a month along with the facility owner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 255325 Department of Health & Human Services Printed: 09/08/2025 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 255325 B. Wing 02/20/2025

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

Wisteria Gardens 5420 Highway 80 East Pearl, MS 39208

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 observations, interviews, and record and facility policy review, the facility failed to follow infection Residents Affected - Few prevention guidelines in two (2) of (10) observed care procedures as evidenced by staff did not don (put on) appropriate personal protective equipment (PPE), including gowns, per Enhanced Barrier Precautions (EBP)

during Percutaneous Endoscopic Gastrostomy (PEG) tube and Foley catheter care for Resident #43 and Resident #251.

Findings Include:

A record review of the facility's policy Enhanced Barrier Precautions dated April 2024 revealed .Policy Interpretation and Implementation: 1. EBP will be used in conjunction with standard precautions and expand

the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug resistant organism (MDROs) to staff .

Resident #43

On February 19, 2025, at 1:42 PM, Licensed Practical Nurse (LPN) 1 was observed providing care to Resident #43's PEG tube site. LPN #1 did not don a gown before initiating the procedure and completed the entire care process without wearing a gown.

During an interview at 1:42 PM, LPN #1 confirmed that EBP signage was posted on Resident #43's door.

She acknowledged that the signage indicated that a gown and gloves should be worn when providing care.

She further stated that she should have donned a gown before entering the resident's room to perform care, as the resident had a PEG tube that required site care, and failure to wear PPE could contribute to infection transmission.

A review of the Admission Record revealed Resident #43 was admitted to the facility on [DATE REDACTED] with diagnoses that included Cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery.

A record review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition.

A record review of Resident #43's Order Summary Report with active orders as of 2/29/25 revealed an order dated 1/21/2025 Clean PEG tube site with normal saline. Pat dry. Cover with gauze, and secure with tape daily on every day shift.

Resident #251

On February 19, 2025, at 1:55 PM, Certified Nurse Aide (CNA) 1 was observed providing Foley catheter care for Resident #251. CNA #1 did not apply a gown before starting the procedure and completed the catheter care without wearing a gown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 255325 Department of Health & Human Services Printed: 09/08/2025 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 255325 B. Wing 02/20/2025

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

Wisteria Gardens 5420 Highway 80 East Pearl, MS 39208

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 During an interview on February 19, 2025, at 2:10 PM, CNA #1 confirmed that she did not wear a gown

during the procedure but stated that she should have worn one, as the resident was on EBP. She Level of Harm - Minimal harm or acknowledged that a sign on the resident's door indicated that the resident had a Foley catheter, requiring potential for actual harm staff to wear gowns to prevent infection transmission.

Residents Affected - Few A review of Resident #251's Admission Record revealed the resident was admitted on [DATE REDACTED], with diagnoses that included Chronic kidney disease, Stage 3B.

A review of Resident #251's MDS revealed the resident had a BIMS score of 3, indicating severely impaired cognition.

A record review of Resident #251's Order Summary Report with active orders as 2/19/25 revealed a physician order dated 2/18/2025 8 (eight) ounces of water every 8 hours for hydration. An additional order dated 2/7/2025 revealed Monitor output of cath (catheter) every shift.

During an interview on February 19, 2025, at 2:44 PM, the Infection Preventionist (IP) nurse stated that EBP requires staff to wear gowns and gloves when providing hands-on care to residents with invasive lines and tubes, such as PEG tubes or Foley catheters. She emphasized that gowns prevent the spread of MDROs and staff are expected to comply with PPE requirements per facility policy.

During an interview on February 19, 2025, at 3:49 PM, the Director of Nursing (DON) stated that EBP requires gowns to be worn when caring for residents with MDROs, chronic wounds, Foley catheters, or PEG tubes, as these conditions place residents at increased risk for infection. The DON further stated that staff have been in-serviced on infection control protocols and are expected to follow Centers for Disease Control and Prevention (CDC) guidelines and facility policy to prevent the spread of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 255325