Ms Care Center Of Greenville

Based on staff interview, record review, and facility policy review, the facility failed to accurately complete Section A of the Minimum Data Set (MDS) for a resident with a serious mental illness (SMI) for one (1) of 21 MDS reviewed. Resident #23
Findings Include:
Review of the facility policy titled Accuracy of Assessments unrevised revealed, The facility must ensure the assessment represents accurately the resident's status during the observation/look back period. The assessment must be reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline.
Record review of the Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 11/02/16 revealed under, Mental Health: The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary a diagnosis of Schizophrenia, paranoid type and under, Axis I secondary a diagnosis of Psychotic disorder.
Record review of the Annual MDS with an Assessment Reference Date (ARD) of 4/18/24, revealed under, section A1500, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? No was marked.
An interview with the MDS Nurse on 2/04/25 at 3:10 PM confirmed, Resident #23 had a SMI and revealed the MDS was not coded correctly. She explained that she kept a list of the residents that had a Level II but must have overlooked it. The MDS Nurse revealed the purpose of having an accurate assessment was for the staff to provide the best possible care for the residents.
An interview with the Administrator on 2/5/25 at 11:36 AM, revealed her expectations were for the MDS to be checked and submitted accurately, so the residents get the best quality of care for mental health.
Record review of the admission Record revealed the facility admitted Resident #23 on 10/12/16 with medical diagnoses that included Paranoid Schizophrenia, Unspecified Psychosis and Hallucinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to honor a resident's rights to make her own healthcare decisions for end-of-life care for one (1) of 24 residents reviewed for advanced directives. Resident #3
Findings include:
Record review of the facility policy titled, Advance Directives with a revision date of 9/2022 revealed The resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Facility will inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment at the resident's option and to formulate an Advanced Directive.
Record review of the Physician Statement of Status of Mental Capacity of Resident dated 1/23/24 revealed that the physician checked Competent, revealing that the resident was able to make her own decisions.
Record review of the DNR (Do Not Resuscitate)/Full Code Request and Consent form dated 1/23/24 revealed Resident #3 had not signed her consent form and that it was signed by a family member.
In an interview on 2/04/25 at 3:00 PM, Resident #3 revealed she could make her own decisions, and when she was admitted to the facility, no one talked with her about her end-of-life wishes. She revealed her niece had already signed all the paperwork and she did not sign her own Advance Directive. She stated, I had my legs cut off, not my brain, and revealed no one had gone over the paperwork with her.
An interview on 2/04/25 at 3:31 PM, with the admission Nurse revealed that she met with the family and had the paperwork signed prior to the resident's admission. She revealed that their physician also sees the resident prior to admission and deems the resident competent or non-competent in determining whether they can sign their own paperwork. She revealed Resident #3 was deemed competent; however, the niece signed the Advance Directive instead of the resident. She revealed that Resident #3 was able to make her own decisions and should have been given the opportunity to make her own decisions regarding her Advance Directive.
An interview on 2/05/25 at 9:40 AM, the Administrator revealed that if a resident is able and competent to sign their own advance directive, the facility should go over the paperwork with the resident and allow them to sign.
Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease with Heart Failure, Cerebral Infarction, Acquired absence of right leg below the knee, and Acquired absence of left leg above the knee.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/6/25, revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #3 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review and facility policy review the facility failed to report an allegation of abuse when a resident reported that a Certified Nursing Assistant (CNA) balled up her fist, placed her knuckles into the resident's thigh and twisted for one (1) of eight (8) residents reviewed for abuse. Resident #1.
Findings include:
Record review of the facility policy, titled Freedom from Abuse, Neglect and Exploitation revealed, It is the policy of the facility to provide services based on the following requirement .Reporting of Alleged Violations .The facility will ensure that all alleged violations involving abuse .are reported immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the Administrator of the facility and State Survey Agency, Adult Protective Services and local law enforcement in accordance with state law .
A record review of the facility Resident Incident Report for Resident #1, dated 5/26/24 and completed by Licensed Practical Nurse (LPN) #1, revealed that on 5/26/24, Resident #1 reported that CNA #2, who changed her on the previous shift balled up her fist and placed her knuckles into her thigh and twisted, and pointed at her left thigh.
A record review of a witness statement from CNA #1, dated and timed 5/26/24 at 1:10 AM, revealed that Resident #1 told her that on 5/26/24 at 10:30 PM, the CNA took her knuckle and pushed it into the back of her left thigh.
In an interview with Resident #1 on 6/3/24 at 2:06 PM, stated that she could not remember the day but when CNA #2 was turning her to clean her up it felt like she was pushing her in the thigh with her fist.
During a telephone interview with LPN #1 on 6/3/24 at 2:45 PM, she confirmed that on 5/26/25 around 1:15 AM, CNA #1 informed her that Resident #1 stated that on the previous shift CNA #2 balled up her fist and placed her knuckles into her thigh and twisted.
LPN #1 stated that she followed-up with Resident #1 and the resident verified that CNA #2 balled up her fist, placed her knuckles into her thigh and twisted. She stated that she was concerned about the report from the resident and notified the on-call Registered Nurse (RN) because it was an allegation of abuse.
In an interview with RN #1 on 6/3/24 at 3:15 PM, she verified that she was the on-call RN on 5/26/24. She stated she received notification from LPN #1 on 5/26/24, of Resident #1's allegation of CNA #2 balling up her fist, placing her knuckles into her thigh and twisting. She stated that on 5/26/24 at 6:00 AM, Resident #1 told her that CNA #2 had come into the room to clean her up and asked her to grab the rail and hold herself. Resident #1 then told RN #1 that she felt CNA #2's fist smash into her left thigh. RN #1 stated that she notified the Administrator and Director of Nursing (DON) immediately because Resident #1's statement was an allegation of abuse.
On 6/3/24 at 3:25 PM, during an interview with the DON, she verified that she received a report of Resident #1's allegation from RN #1 on 5/26/24. She stated that the facility did not report Resident #1's complaint of CNA #2 balling up her fist, placing her knuckles into her thigh and twisting because the resident has a history of making false accusations and on completion of their investigation, they could not validate the incident occurred. The DON agreed that Resident #1's complaint should have been considered an allegation of abuse and should have been reported as such.
In an interview with the Administrator on 6/3/24 at 4:30 PM, she stated that Resident #1's complaint was not reported because they did not feel it was an allegation of abuse.
A record review of the Face Sheet for Resident #1 revealed that the facility admitted the resident on 1/23/2017 with a diagnosis of Flaccid Hemiplegia affecting left non-dominant side.
A record review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and facility policy review the facility failed to prevent the possibility of infection as evidenced by failing to perform hand hygiene, provide a clean workspace, change gloves and keep oxygen tubing off the floor and in a plastic bag for one (1) of four (4) resident care observations. Resident #21
Findings include:
A review of the facility policy titled Infection Control, revised September 2022, revealed: Staff involved in direct resident contact will perform hand hygiene (even if gloves are used). Hand hygiene is performed: After removing personal protective equipment (e.g., gloves, gown, facemask). Gloves changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care. Oxygen tubing, when not in use, store the mask/cannula in a plastic bag labeled with the resident's name and date.
An observation, on 07/17/23 at 11:11 AM, revealed Resident #21's oxygen tubing and humidifier bottle were not labeled and dated. The cannula was laying on the floor underneath the overbed table.
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An observation and interview on 07/19/23 at 8:16 AM, with the Director of Nursing (DON) confirmed, Resident #21's oxygen tubing was laying on the floor. The DON stated that the tubing should be stored in a plastic bag when not in use and should not be laying on the floor to prevent infection.
An observation on 07/19/23 at 08:24 AM, of incontinent care with Certified Nursing Assistant (CNA) #1 revealed, she set up a wash basin on the overbed table of Resident #21. There was an open container of juice, toothpaste, a comb, jewelry, and a contact case on the same table with the wash basin. CNA #1 did not change gloves after setting up the wash basin. CNA #1 wet a bath cloth and wiped across the resident's lower abdomen and groin areas and placed the contaminated bath cloth back in clean water basin and reused it. CNA #1 wiped more than once with the same area of the bath cloth and left the dirty bath cloth on the bed. CNA #1 positioned Resident #21 on her right side. CNA #1 then got a new bath cloth and did not change gloves. CNA #1 looked over resident #21's room for briefs touching items in drawers, touching furniture, the bed and the privacy curtain. CNA #1 then put on clean gloves without performing hand hygiene. CNA #1 then applied skin protectant, did not change gloves and then applied a clean brief to Resident #21.
An interview on 07/19/23 at 09:45 AM, with Registered Nurse (RN)#1 and Licensed Practical Nurse (LPN) #1 regarding incontinent care process revealed, LPN #1 stated that gloves should be changed frequently, and staff's hands should be washed each time gloves are changed. LPN #1 stated that the staff should clean with a different area of the bath cloth from top to bottom with one swipe with each different location. RN #1 stated that CNA #1 should have used two wash basins.
An interview on 07/19/23 at 10:00 AM, with CNA #1 confirmed she put the dirty bath cloth back into the clean water and contaminated the clean water. CNA #1 stated that there should not have been anything on the table with the basin and confirmed there was open apple juice and other items on the table. She stated that having the items on the table was an infection control problem.
An interview on 7/20/23 at 9:50 AM, with the DON confirmed staff does annual competency check offs, but the staff does get nervous.
Record review of the Face Sheet for Resident #21 revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Human Immunodeficiency Virus, Essential Hypertension and Cough.
A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review and facility policy review the facility failed to provide appropriate incontinent care treatment to prevent the potential for infection for one (1) of four (4) residents observed for care observations. Resident #21.
Findings include:
A review of the facility policy titled Incontinence, revised September 2022, revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. The Policy Explanation and Compliance Guidelines revealed: Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.
An interview on 07/17/23 at 11:13 AM, with Resident #21 revealed she doesn't feel like they clean her good.
On 7/19/23 at 8:02 AM, an observation of Resident #21's incontinent care with Certified Nursing Assistant (CNA) #1 revealed that she did not change gloves after setting up the wash basin. CNA #1 wet a bath cloth, wiped across the resident's lower abdomen and groin areas. She then placed the contaminated bath cloth back in the clean water basin and wiped more than one area with the same area of the bath cloth.
An interview on 07/19/23 at 09:45 AM, with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 regarding the incontinent care process, LPN #1 stated that the staff should clean with a different area of the bath cloth from top to bottom with one swipe with each different location. RN #1 stated that CNA #1 should have used two basins.
An interview on 07/19/23 at 10:00 AM, with CNA #1 regarding incontinent care confirmed that she put the dirty bath cloth back into clean water and contaminated the clean water and she should not wipe more than once with the same area of the bath cloth.
An interview on 7/20/23 at 9:50 AM, with the Director of Nursing (DON) confirmed staff does annual competency check offs but the staff does get nervous.
A review of facility in-service records revealed that CNA #1 attended an in-service on incontinent care on 01/30/23 and successfully performed skills check off for incontinent care on 07/20/22.
A review of the facility Face Sheet for Resident #21 revealed she was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Intracerebral Hemorrhage, and Needs assistance with personal care.
A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview, record review and facility policy review the facility failed to follow a physician prescribed fluid restriction for (1) one of (4) four residents on dialysis. Resident #69
Findings include:
Review of the facility policy titled Fluid Restriction policy dated 12/13/2018 revealed, Fluid restriction orders will be carried out as ordered by the physician by the nursing and dietary departments 2. Fluids ordered for the resident will be divided between the Nursing and Dietary departments. 3. Fluids determined to be used by Dietary will be sent out on the meal tray. 4. All fluids given by the aides will be recorded in the resident's room on a fluid intake form. 5. Fluids determined to be used by nursing will be divided between their medication passes. 6. Fluids given by the nurses on medication passes are to be recorded on the eMAR (electronic medication administration record). 7. Fluid intake sheet will be totaled, and a 24-hour total entered on the eTAR (electronic treatment administration record).
An observation and interview with Resident #69 on 7/18/23 3:15 PM, revealed that he did not have a water pitcher in his room. The resident revealed that he goes by his fluid restriction. He stated, Pretty much, I drink only what they bring me.
Record review of the July 2023 Physician Orders revealed an order dated 6/06/23, 1200 cc (cubic centimeter) fluid restriction R/T (related to) ESRD (End Stage Renal Disease)
Record review of the July 2023 Medication Administration Record (MAR) revealed Resident #69 did not have an order listed for fluid restriction or a monitoring tool to track fluid intake within a 24-hour period.
An interview with the Director of Nursing (DON) on 7/18/23 at 4:15 PM, revealed that the aides would know not to give Resident #69 any fluids because he doesn't have a water pitcher in his room.
An interview on 7/18/23 at 4:30 PM with Medical Records revealed that Resident #69's fluid restriction was not added on the Activities of Daily Living (ADL) task for the aides to document.
An interview with the DON on 7/18/23 at 4:45 PM, confirmed that the facility did not monitor or document Resident #69's fluid intake on the MAR or ADL's. She confirmed that this should have been done, and that this could cause the resident to be in fluid volume overload. She also confirmed that they did not provide a breakdown of the total number of fluids that the resident should receive between nursing and the dietary department in a 24 -hour period. She stated, No, we didn't do it.
An interview with Certified Nurse Aide (CNA) #3 on 7/19/23 at 8:00 AM, revealed she was able to identify if a resident was on a fluid restriction because the resident will not have a water pitcher in their room. She stated, The fluid restriction will be on their meal slip. She revealed that Resident #69 does go by his ordered fluid restriction. She stated, He may ask for 1/2 (one-half) cup of coffee in the mornings, and we have to check with the nurse before getting it.
An interview with Registered Nurse (RN) #2 on 7/19/23 at 2:10 PM, revealed Resident #69 did not have an order for a fluid restriction on the MAR or ADL. She stated, They (the staff) wouldn't know the resident was on a fluid restriction because it's not on there (the ADL or MAR).
An observation of Resident #69's Medical Record with the Minimum Data Set (MDS) on 7/20/23 at 9:15 AM, confirmed that the resident did not have a fluid restriction task on the ADL's.
Record review of the Face Sheet for Resident #69 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Systolic Congestive Heart Failure, Hypokalemia, Gastro-Esophageal Reflux Disease Without Esophagitis, and ESRD.
Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 7/07/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident #69 was unable to complete the BIMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to post an oxygen in use sign outside the door and to label oxygen tubing and a humidifier bottle for one (1) of four (4) residents reviewed that were receiving oxygen. Resident #21.
Findings include:
Record review of a procedure Nursing Department Infection Control undated, revealed .Respiratory Equipment: .Oxygen tubing .When not in use, store the mask/cannula in a plastic bag labeled with the resident's name and date .
An observation on 07/17/23 at 11:11 AM, revealed, Resident #21's oxygen tubing and humidifier bottle were not labeled and dated. The cannula was laying on the floor underneath the overbed table. No oxygen in use signage was on the door.
An observation and interview on 07/19/23 at 8:16 AM, with the Director of Nursing (DON) confirmed, Resident #21's oxygen tubing was laying on the floor and the oxygen tubing and humidifier water bottle was not labeled. The DON stated that the procedure should be to change tubing every seven days and that tubing should be labeled with time, date and initials. The DON stated that the water bottle on the concentrator should be changed every thirty days and should be labeled with time, date, and initials. The DON stated that the tubing should be stored in a plastic bag when not in use and should not be laying on the floor to prevent infection. The DON confirmed that there was not an oxygen sign on the door.
A record review of the Physician Orders dated 07/17/23 revealed Oxygen at two (2) liters per minute by nasal cannula as needed.
An observation and interview with Resident #21 on 07/19/23 at 04:30 PM, revealed the oxygen tubing and humidifier bottle remained unlabeled and the tubing was laying on the floor. Resident #21 stated she doesn't use it all the time, just when she thinks she needs it.
A review of the facility Face Sheet revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Human Immunodeficiency Virus, Essential Hypertension and Cough.
A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #21 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review and facility policy review the facility failed to implement a care plan for shaving for Resident #26, failed to develop a care plan for maintaining a PICC (peripherally inserted central catheter) line for Resident #62, and failed to implement a care plan for fluid restriction for Resident #69. This was for three (3) of 19 care plans reviewed.
Findings include:
Review of the facility policy titled Develop/Implement Comprehensive Care Plan with a revision date of September 2022 revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights and that includes measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required . 4. The resident's goals for admission and desired outcomes
Resident #26
Record review revealed the resident had a care plan with problem onset date of 9/24/2015, Requires assistance with ADL's (Activities of Daily Living) due to DX (diagnoses) of Parkinson, Decreased Muscle Strength, Impaired Mobility, and Decreased Bed Mobility .Approaches .Assist with ADL's as needed .
An observation of Resident #26 on 07/17/23 at 11:39 AM revealed she was sitting up in her wheelchair in the day room with a patch of white hair on both sides of her chin that is approximately 1/4 inch wide and approximately 1/4 inch long.
An interview on 7/20/23 at 8:30 AM, with the Administrator and the Corporate Administrator confirmed that the residents Activities of Daily Living (ADL) care plan was not being implemented since the resident had hair on her chin and needed to be shaved.
Record review of Resident #26's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia without Behavioral Disturbance.
Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 5/29/23 revealed in Section G that the resident required total dependence with bathing and in Section C a Brief Interview for Mental Status (BIMS) score of three (3), which indicates the resident is severely cognitively impaired.
Record review of Resident #62's Care Plans revealed a care plan was not developed for the PICC line maintenance.
An interview with Registered Nurse (RN) #2 on 7/20/23 at 8:35 AM, confirmed that Resident #62 did not have a care plan for PICC line care. She stated, No ma'am, it's not in there; That's what I'm working on now. She revealed the purpose of developing and implementing a care plan was to make sure that the care was done and individualized to that resident.
Record review of Resident #62's Electronic Medication Administration Record (eMAR) revealed an order dated 6/21/23 to flush the PICC line in the left arm with 10 cubic centimeters (CC) of normal saline (NS) before and after each antibiotic.
Record review of the Face Sheet revealed Resident #62 was admitted to the facility on [DATE] with medical diagnoses that included Benign Prostatic Hyperplasia, Unspecified Systolic Congestive Heart Failure and Unspecified Atrial Fibrillation.
Resident #69
Record review of Resident #69's care plan dated 7/13/23 revealed under intervention, 1200 cc (cubic centimeters) fluid restriction. Dietary to provide 720 cc. Nursing to provide 480 cc with med pass.
On 7/18/23 at 4:45 PM, an interview with the DON confirmed that the facility did not monitor or document Resident #69's fluid intake on the Medication Administration Record (MAR) or Activities of Daily Living (ADL's) record.
An interview with RN #2 on 7/19/23 at 2:10 PM, revealed the purpose of the care plan was to tell staff what the problem was with the resident and how to address it. She confirmed that staff did not follow the fluid restriction care plan for Resident #69. She stated, They wouldn't know the resident was on a fluid restriction.
An interview with the DON on 7/19/23 at 2:30 PM confirmed that Resident #69's care plan was not followed for the fluid restriction and acknowledged that it should have been.
An interview with the Assistant Director of Nursing (ADON) on 7/20/23 at 8:40 AM, revealed the purpose of the care plan was to determine what kind of care the resident was to receive. She confirmed that by not developing or implementing the care plan, the facility may fail to provide the care that was needed.
Record review of the Face Sheet for Resident #69 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Systolic Congestive Heart Failure, Hypokalemia, and Major Depressive Disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, record review and facility policy review the facility failed to flush a residents PICC (peripherally inserted central catheter) line for (1) one of (7) seven residents reviewed during medication observations. Resident #62.
Findings include:
Review of the facility policy titled Central Venous Catheter Procedures PICC/Central Venous Line Dressing and Caps (needleless connector) Change and Care policy revealed under, Policies and Guidelines . Flush PICC line every 12 hours or as ordered by physician .
An observation and interview on 7/19/23 at 10:56 AM, with Resident #62 revealed a PICC line to his left upper arm with a dressing intact. Resident #62 revealed he went to the doctor recently and the device was flushed, but they do not flush it here at the facility.
Record review of the July 2023 Medication Administration Record (MAR) for Resident #62 revealed an order dated 6/21/23, Normal Saline Flush 1 ML (milliliter) SYR (syringe) flush PICC (peripherally inserted central catheter) line left arm with 10 cc (cubic centimeters) normal saline before and after each antibiotic with a stop date of 7/04/23.
Record review of the Physician Orders for the month of July 2023 revealed an order dated 6/22/23, PICC (peripherally inserted central catheter) line left arm sterile dressing change every 7 days: Sterile gloves clean gloves; mask; 4×4's; alcohol swabs occlusive dressing; Barrier for sterile field;
An interview with the Assistant Director of Nursing (ADON) on 7/19/23 at 11:00 AM, revealed the resident was recently sent to the hospital for a blood transfusion. She revealed the Nurse Practitioner (NP) was waiting to see if the resident would require any further blood work or transfusions before removing the PICC line and she revealed that the resident had a follow-up appointment with the urologist on 7/17/23 and the NP wanted to leave the PICC line in place until that appointment.
An interview with the ADON on 7/19/23 at 1:15 PM, revealed she was not aware that Resident #62's PICC line was not being flushed. She stated, We were flushing it. She revealed that the resident was receiving antibiotics for a UTI (urinary tract infection) and the PICC line flush order must have stopped when the antibiotic was completed on 7/04/23. She confirmed that they should be flushing it every day to maintain patency and prevent occlusion.
An interview with the Director of Nursing (DON) on 7/19/23 at 1:30 PM, revealed she was not aware that Resident #62's PICC line was not being flushed every day. She stated, The order was entered with a stop date for when the IV antibiotic was completed. She revealed the NP wanted the line left in until he followed up with the Urologist.
An interview with the NP on 7/19/23 at 1:45 PM, revealed the PICC line should still be flushed, and she stated, Yes, I didn't know that it wasn't, I can re-order that. She confirmed that flushing the PICC line could prevent the line from occluding.
An interview with the DON on 7/19/23 at 2:00 PM, confirmed that Resident #62 should have an order to flush his PICC line and confirmed that by not doing this, the line could clot off.
Record review of the Face Sheet revealed Resident #62 was admitted to the facility on [DATE] with medical diagnoses that included Benign Prostatic Hyperplasia, Unspecified Systolic Congestive Heart Failure and Unspecified Atrial Fibrillation.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 12, indicating resident #62 is moderately cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, resident interview, record review and facility policy review the facility failed to shave a resident that was dependent on staff for bathing and personal hygiene for one (1) of 74 residents reviewed during initial tour. Resident #26
Findings Include:
Review of the facility policy titled Mississippi Care Center-ADL (Activities of Daily Living) Care Provided for Dependent Residents with a review date of 09/22 revealed, Residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
An observation on 07/17/23 at 11:39 AM, revealed Resident #26 sitting up in her wheelchair in the day room with a patch of white hair on both sides of her chin that is approximately 1/4 inch wide and approximately 1/4 inch long.
An interview and observation on 7/18/23 at 12:45 PM, with Certified Nurse Assistant (CNA) #2 revealed that Resident #26 is in an A bed and those baths are performed on Monday-Wednesday and Friday's. She stated that all personal hygiene care goes along with the resident's baths to include shaving. During an observation of Resident #26, CNA #2 confirmed that Resident #26 had hair on her chin and when the CNA asked the resident if she wanted it shaved off , the resident stated, If it's there then it needs to be off, I did not even know it was there CNA #2 confirmed that she should have been shaved and she would take care of it.
An interview on 7/18/23 at 1:10 PM, with the Director of Nurses (DON) confirmed that female residents need to be shaved of facial hair when they have their baths unless the resident refuses.
Record review of Resident #26's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia without Behavioral Disturbance.
Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/29/23 revealed in Section G that the resident required total dependence with bathing and in Section C a Brief Interview for Mental Status (BIMS) score of 3, which indicates the resident is severely cognitively impaired.

Based on observation, staff interview, facility policy review, the facility failed to prevent the potential of injury to a resident, as evidenced by the absence of a wheelchair arm rest exposing a protruding screw for one (1) of 18 residents reviewed. Resident #1
Findings Include:
Record review of the facility policy titled Equipment undated, revealed wheelchairs, walkers, crutches, and canes will be provided to the residents and are maintained as the property of the facility.
An observation on 03/01/21, at 02:53 PM, revealed the left arm rest missing on Resident #1's wheelchair. Further observation revealed a screw that was sticking upward approximately 1/2 inch out of the metal piece where armrest should be.
An interview on 03/01/21, at 02:54 PM, with Resident #1, confirmed that he does get up in the wheelchair at times.
An observation on 03/03/21, at 11:14 AM, revealed Resident #1 up in his wheelchair with no arm rest on the left side. The screw was sticking upwards from metal bar. Resident #1 had on a long sleeve shirt.
An observation and interview on 03/03/21, at 11:25 AM, with Licensed Practical Nurse (LPN) #1 confirmed the wheelchair did not have an arm rest on the left side. She confirmed the screw was sticking up and could cause a skin tear and possible infection. LPN #1 pulled Resident #1's sleeve up. There was no injury to his arm.
An interview on 03/04/21, at 11:30 AM, with the Director of Nursing (DON) revealed that whoever notices equipment needs repair should report it. The DON stated the wheelchair arm should have been fixed, because getting the resident up in the wheelchair without the arm rest on and the screw sticking up could have caused an injury to the resident.

Based on observation, staff interview, facility policy review and record review, the facility failed to ensure staff wore masks appropriately covering the nose and mouth to prevent the possible spread of the COVID-19 virus for three (3) of five (5) survey days.
Findings Include:
The facility policy titled, Personal Protective Equipment, dated 4/1/20, revealed this facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff.
An observation of the dietary department on 3/2/21, at 11:00 AM, revealed the Dietary Manager (DM) wearing her mask below her nose. Dietary staff #1 and #3 had their masks below their nose while preparing food and setting up trays for the lunch meal.
An observation, on 3/3/21, at 1:45 PM, revealed Dietary Staff #2 in the dietary department with his face mask below his nose.
An interview, on 3/3/21, at 2:30 PM, with the Dietary Manager (DM), revealed that she and all workers should have their masks over their mouth and nose.
On 3/4/21, at 2:14 PM, an interview with Dietary staff #2 revealed he stated that he did not realize his mask was not over his nose. He stated that his mask should be covering his nose because of the virus. Dietary staff #2 confirmed he has had in service education on proper wearing of Personal Protective Equipment (PPE).
An interview, on 3/4/21, at 11:30 AM, with Dietary staff #1 revealed that when she talks her mask comes down. She stated that this was not good because when talking saliva could come in contact with others and the food and possibly spread the virus. Dietary staff #1 stated that she should get another mask that fits and does not slide down. Dietary staff #1 confirmed she has had in-service education regarding proper wearing of masks.
On 3/3/21, at 2:32 PM, an observation revealed Licensed Practical Nurse (LPN) #2 sitting at the nurse's desk with her mask not covering her nose. She then walked down the hall and provided resident care with her mask not covering her nose.
On 3/3/21, at 3:40 PM, an interview with LPN #2 revealed that she should wear her mask covering her mouth and nose. She stated that she guessed she was just not paying attention. LPN #2 stated that not properly wearing her mask could cause her or the resident to breathe in germs and COVID-19 is in the air. She stated that she has had several in-services on COVID-19, and they have been told to keep their masks on at all times.
On 3/3/21, at 2:48 PM, an interview with the Director of Nursing (DON) revealed that all the staff know they are supposed to wear masks, goggles, or face shields properly when on the floor because they are trying to protect residents from getting COVID-19.
On 3/2/21, at 4:00 PM, the Laundry Supervisor did not have a mask on during an interview with this surveyor. She did put a mask on during the interview. The Laundry Supervisor stated that she should wear a mask at all times in the laundry and a mask and goggles when she goes on the floor. She stated that she takes her mask off when she is in the laundry by herself. The Laundry Supervisor stated that according to facility policy and education, she should have a mask on all the time.
Record review of a staff posting revealed all staff must wear facemasks at all times while at work. KN95 or N95 masks are to be worn on second and third floors at all times.
Record review revealed that LPN #2, the Dietary Manager and Dietary Staff #1 and #3, and the Laundry Supervisor had attended in-service education classes related to face masks in November 2020. Dietary Staff #2's signature did not appear on any in-service sheets reviewed for proper PPE use.

Based on observation, staff interview, facility policy review the facility failed to label and date left over food in the refrigerator for one (1) of two (2) tours.
Findings Include:
Review of the facility policy titled, Food Storage Labeling, revised 10/17, revealed that the facility will ensure the safety and quality of food by following good storage and labeling procedures. The procedure revealed suggested labeling include the common name and the date of preparation or the use by date.
An observation of the standalone refrigerator on 3/2/21, at 11:30 AM, revealed metal containers of fortified sweet potatoes, vegetable soup, and chicken soup not labeled or dated.
An interview, on 3/2/21 at 11:45 AM with the Dietary Manager (DM), confirmed the containers should be labeled and dated in order to know how long they had been in the refrigerator, so they could be discarded. The DM revealed she did not know what staff member placed the containers in the refrigerator unlabeled. The DM stated that bad food could cause sickness.
An interview, on 03/04/21 at 12:45 PM, with the DM revealed that she and her staff were aware to date and label items in the refrigerator. She confirmed that they failed to date and label the fortified sweet potatoes, the vegetable soup, and the chicken soup. The DM stated that her staff had been in serviced on labeling and dating refrigerated items.
Record review revealed an in-service dated 1/12/21, provided by the DM, addressed labeling, and dating of foods. Record review revealed four (4) staff members attended.