Greenbriar Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Diberville, Mississippi.
- Location
- 4347 West Gay Road, Diberville, Mississippi 39540
- CMS Provider Number
- 255323
- Inspections on file
- 21
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Greenbriar Nursing Center during CMS and state inspections, most recent first.
A resident with an ADL self-care deficit and documented need for substantial/maximal assistance with bed mobility had a care plan requiring two staff for turning and repositioning in bed. Despite this, a CNA provided in-bed care and performed a linen and brief change alone, during which the resident rolled to assist, rolled too far, and fell from the bed. The CNA reported attempting to prevent the fall as the resident grabbed the bed rail but could not hold herself up. An X-ray confirmed a proximal humeral fracture of the left shoulder, and facility staff later acknowledged that the established two-person bed mobility care plan had not been followed.
A resident who was cognitively intact but required substantial/maximal assistance for rolling in bed, with a documented care plan specifying two-person assistance for turning and repositioning, was being provided an in-bed linen and brief change by a CNA working alone. During the process of rolling the resident and removing soiled linens, the resident rolled too far and fell from the bed despite attempts by both the resident and the CNA to prevent the fall, resulting in a proximal humeral fracture confirmed by X-ray and subsequent hospital transfer.
The facility failed to maintain a clean, comfortable, and homelike environment when ongoing shortages of towels, washcloths, sheets, and bed pads left staff without adequate linens for resident care. Surveyors observed empty linen closets, and CNAs reported repeated morning shortages over several days, leading them to use wipes or pillowcases for hygiene and perineal care, which delayed care. A resident reported daily linen shortages, late bed-making, and lack of bed pads or linens at night. The Housekeeping Supervisor cited limited laundry hours and staffing issues, while the DON and Administrator acknowledged persistent shortages over several weeks, with concerns that staff were discarding heavily soiled linens instead of laundering them and documentation showing closets consistently low during morning inventories.
A CNA did not follow hand hygiene protocols during perineal care for a resident with severe cognitive impairment and dementia. The CNA failed to wash hands after removing gloves, when exiting and reentering the room, and between glove changes, contrary to facility policy. Staff interviews confirmed the lapses and acknowledged the required procedures were not followed.
A resident with severe cognitive impairment was left exposed during perineal care when a CNA exited the room twice without covering the resident, resulting in embarrassment and a lack of privacy. Facility staff and the DON confirmed this was a dignity issue and not in accordance with resident rights policies.
A resident's privacy was compromised when a sign indicating NPO status was posted on the outside of her door, making confidential care information visible to anyone in the hallway. The DON and staff confirmed that neither the resident nor her representative were asked for permission, and that all necessary care information was already accessible to staff through internal systems. The resident had a history of hemiplegia and was receiving enteral feedings, with moderately impaired cognition.
The QAPI Committee failed to maintain effective oversight and monitoring, resulting in a repeat citation for infection control deficiencies, including improper PEG tube and perineal care, as identified through record review, staff interviews, and policy review.
A resident with severe cognitive impairment alleged sexual abuse, but the LTC facility failed to report the allegation within the required two-hour timeframe. The resident exited her room with a bowel movement and blood, stating she was raped. Despite being aware of the allegation, an LPN and two CNAs did not report it to the administration, delaying the investigation and reporting process.
Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Fall and Fracture
Penalty
Summary
The deficiency involved the facility’s failure to implement a comprehensive, person-centered care plan requiring two staff to assist with bed mobility. The resident had an ADL self-care performance deficit care plan initiated on 7/14/25, which specified that bed mobility required assistance from two staff to turn and reposition in bed. A comprehensive MDS with an ARD of 1/29/26 documented that the resident was cognitively intact with a BIMS score of 15 and required substantial/maximal assistance for rolling left and right in bed. Despite these documented needs and the care plan intervention, a CNA provided in-bed care, including linen and brief changes, without the required second staff member. On 2/11/26 at approximately 10:05 PM, while CNA #1 was changing the resident’s bed linens and brief alone, the resident rolled to assist with care and rolled too far, exiting the bed and landing on the floor. CNA #1’s written statement indicated she was pulling the sheet from under the resident when the resident rolled and fell, and that the resident was not able to hold herself up even after grabbing the bed rail. The resident later reported that the CNA was alone while changing the bed linens when the fall occurred. An X-ray of the left shoulder taken the same day documented a proximal humeral fracture. The facility’s records, including interviews with the care plan nurse and DON, confirmed that the resident’s care plan required two staff for bed mobility and that the CNA did not follow this plan of care.
Failure to Follow Two-Person Assist Requirement During Bed Mobility Results in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident free from accident hazards and to provide adequate supervision during bed mobility, resulting in a fall from bed and injury. On the evening in question, CNA #1 performed an in-bed linen and brief change for Resident #1 without the required two-person assistance. During this care, the CNA rolled the resident to her side to remove soiled linens; as the CNA pulled the sheet from under the resident, the resident rolled too far and fell from the bed to the floor. The CNA reported attempting to reach over and keep the resident from falling, and the resident attempted to hold herself up by grabbing the bed rail, but she was unable to maintain her position and continued to fall. Resident #1 had been admitted with diagnoses including hypertension, and later had an additional diagnosis of a displaced fracture of the upper end of the left humerus, subsequent encounter for fracture with routine healing. The most recent MDS assessment showed the resident was cognitively intact with a BIMS score of 15 and required substantial/maximal assistance for rolling left and right in bed. The Kardex in effect at the time specified that the resident required two staff for turning and repositioning in bed. Despite this documented need, CNA #1 provided the linen and brief change alone and stated she was unsure how many staff were required for bed mobility at that time, even though CNAs had access to the Kardex system and were expected to review it daily. Following the fall, an X-ray of the resident’s left shoulder documented a proximal humeral fracture, consistent with the reported history of a shoulder injury from a fall out of bed. Resident #1 later described that during the linen change she was rolled onto her side, began to fall when the bed pad was removed, tried to stop herself, and that the CNA also tried to catch her but she still landed on her left side on the floor. She reported that the CNA then left the room to obtain assistance, after which nursing staff came to assess her and she was transported to the hospital. The DON confirmed in interview that the fall occurred during a linen change when the CNA did not follow the Kardex requirement for two staff during bed mobility.
Ongoing Linen Shortages Compromise Clean and Comfortable Resident Environment
Penalty
Summary
The facility failed to ensure residents had a safe, clean, comfortable, and homelike environment due to ongoing shortages of clean linens and washcloths. Surveyors observed that a linen closet on one hall contained no towels, washcloths, fitted sheets, blankets, or bed pads, with only one item present, and the owner stated closets would be filled once laundry staff made rounds. Multiple CNAs reported that washcloths, towels, and bed sheets were frequently unavailable in the mornings and had been in short supply for several days, leading them to use wipes or pillowcases to wash residents’ faces or provide perineal care after bowel movements, and that these shortages delayed completion of resident care. A resident reported that linen shortages occurred daily, that his bed was often made later in the day or after lunch, and that at night there were no bed pads or linens available. The Housekeeping Supervisor reported that linen closets were refilled three times daily, there was no overnight laundry shift, laundry staff left in the late afternoon, and the department had been short staffed for about two months. The DON acknowledged staff reports of linen shortages and stated that linens were sometimes hidden in resident rooms, and that wipes were implemented due to the shortages. The Administrator confirmed ongoing washcloth and towel shortages for at least six weeks, reported having to come in early in the morning to wash linens because none were available for residents, and believed staff were discarding heavily soiled linens instead of sending them to laundry. Daily linen issue sheets for several consecutive days showed all linen closets were noted to be low on the morning shift at the time of inventory, demonstrating a persistent lack of adequate clean linens for resident care.
Failure to Perform Hand Hygiene During Perineal Care
Penalty
Summary
A Certified Nurse Aide (CNA) failed to perform proper hand hygiene during perineal care for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. The CNA was observed removing gloves and exiting the resident's room without performing hand hygiene, then returning and continuing care without washing hands. Additionally, after completing care, the CNA removed gloves and applied a new pair before putting on a clean brief, again without performing hand hygiene between glove changes. These actions were in direct violation of the facility's Hand Hygiene Policy, which requires hand hygiene before donning gloves, after removing gloves, and when entering or exiting a resident's room. Interviews with facility staff, including a lead CNA, the CNA involved, the Director of Nursing (DON), and the facility's Infection Preventionist, confirmed that the expected protocol was not followed. All staff acknowledged that hand hygiene should have been performed at each indicated step, and the Infection Preventionist confirmed that lapses in hand hygiene could lead to infection in the resident. The deficiency was identified through observation, interviews, and review of facility policy and resident records.
Failure to Maintain Resident Privacy During Perineal Care
Penalty
Summary
The facility failed to maintain privacy and dignity for a resident during the provision of perineal care. During an observation, a CNA left the resident exposed while exiting the room to get assistance, and the resident was seen pulling at her shirt in an attempt to cover her private area. The CNA returned with another CNA, but later left the room again to retrieve additional towels, once again leaving the resident exposed. Both CNAs and the Director of Nursing confirmed that the resident was left exposed and acknowledged this as a dignity issue. The resident involved had been admitted with a diagnosis of unspecified dementia and was noted to have severely impaired cognition according to her most recent MDS assessment. The facility's policy on resident rights, which includes the right to privacy and dignity, was not followed during this incident. The observations and interviews confirmed that the resident was left exposed on two occasions during care, resulting in embarrassment and a lack of privacy.
Failure to Protect Resident Confidentiality by Posting Clinical Information Publicly
Penalty
Summary
The facility failed to protect the privacy and confidentiality of a resident's medical information by posting a sign indicating "NPO" (Nothing by Mouth) on the outside of the resident's door, making this clinical instruction visible to anyone passing by in the hallway. The facility's policy states that residents have the right to personal privacy and confidentiality of their medical records, including medical treatment information. During interviews, the DON acknowledged that the sign was posted for staff awareness but admitted uncertainty about whether the resident or her family had been informed or given permission for the sign to be displayed. The resident herself confirmed she had not been asked for permission, and her representative also stated he was not consulted about the sign placement. Staff interviews revealed that care information, including NPO status, was accessible to staff through the Kardex and electronic health records, making the public posting of the sign unnecessary. The DON further acknowledged that staff from various departments, as well as visitors and family members, could see the sign, which contained confidential care information. The resident involved had been admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction and was receiving enteral feedings per physician order. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 12.
Repeat Infection Control Deficiency Due to Inadequate QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency related to infection control. Specifically, the facility was cited for failing to provide Percutaneous Endoscopic Gastrostomy (PEG) care in a manner that would prevent the possible spread of infection during an annual recertification survey. Despite the existence of a policy outlining a systematic approach to performance improvement, the same deficiency was cited again during the current survey, indicating that ongoing monitoring and oversight were not maintained. Record reviews confirmed that the facility had previously received a citation for F880-Infection Control, which included failures in providing PEG tube and catheter care according to infection prevention standards. During the current survey, it was observed that perineal care was also not provided in a manner to prevent the possible spread of infection. These findings were based on record review, staff interviews, and facility policy review.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required two-hour timeframe. Resident #1, who was admitted with diagnoses including Dementia and Alzheimer's Disease and had a severely impaired cognition, verbalized an allegation of sexual abuse. On 11/01/2024, Resident #1 exited her room with a bowel movement on her body and stated she was raped. Despite this, the allegation was not reported to the Administrator or Director of Nursing (DON) until 11/06/2024, when the Administrator was informed by a hospital case manager that a complaint would be submitted to the State Agency and Attorney General. The investigation revealed that on 11/02/2024, LPN #1 and CNAs #1 and #2 were aware of the allegation but did not report it to the administration. LPN #1 admitted to notifying the Nurse Practitioner about the bleeding but did not inform the Administrator or DON about the rape allegation, believing there was no basis for it. The facility's policy requires such allegations to be reported to the State Agency, local police, and Attorney General within two hours, but this was not done due to the staff's failure to communicate the incident to the administration.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
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