Perry County Nursing Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to the provision of care in a respectful and dignified manner when staff provided incontinent care for one (1) of nine (9) sampled residents without ensuring privacy. (Resident #1).Findings include:A

review of the facility's document, A Matter of RIGHTS: A Guide to Your Rights and Responsibilities as a Resident, Copyright 2020, revealed, .Dignity and Respect: You have the right to dignity and respect in the care you receive.A review of the facility's Aide Check List, with the latest revision dated December 2020, revealed, .Ensure privacy for Residents.A record review of the admission Record revealed the facility admitted Resident #1 on 8/13/24 and he had diagnoses including Vascular Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated he was severely cognitively impaired.On 10/2/25 at 8:27 AM, during an observation, Certified Nurse Aide (CNA) #1 and CNA #3 were observed providing incontinence care and changing the incontinence brief for Resident #1.

The CNAs lifted the resident using a sit-to-stand lift and removed his brief without pulling either his privacy curtain or that of his roommate. The resident's roommate was lying in bed, facing Resident #1, with a full view of the resident's perineal area. On 10/2/25 at 1:40 PM, during an interview, the Staff Development Coordinator stated the facility provided monthly in-service training on Resident Rights, including each resident's right to respect and dignity. She explained that all new staff received Resident Rights training

during orientation, which included both video and one-on-one instruction on providing respectful and dignified care. She stated that CNAs were instructed to ensure privacy prior to beginning any care procedure and that competency checkoffs for Activities of Daily Living (ADL) care, including incontinence care, required demonstration of privacy measures.On 10/2/25 at 2:13 PM, during an interview, CNA #1 stated she had not considered the privacy issue while changing the resident in front of his roommate. She acknowledged that it was undignified to change the resident in full view of another resident.On 10/2/25 at 2:28 PM, during an interview, CNA #3 stated she was aware that residents had the right to privacy during care to maintain dignity. She acknowledged that she should have ensured the resident's privacy prior to beginning incontinence care and stated that the privacy curtain did not fully close around the resident's bed.On 10/2/25 at 2:55 PM, during an interview, the Director of Nursing (DON) stated her expectation was for staff to provide privacy for residents by using the room's privacy curtains during all personal care procedures. She confirmed that CNA #1 and CNA #3 failed to ensure Resident #1's privacy prior to providing incontinence care and stated that this failure violated the resident's right to respectful and dignified care.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perry County Nursing Center

202 Bay Avenue West Richton, MS 39476

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 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure medications were administered in accordance with professional standards of quality and accepted standards of practice by not referencing the Medication Administration Record (MAR) during medication preparation and administration for one (1) of three (3) residents observed for medication administration (Residents #8).Findings include:Review of the facility's Oral Medication Administration Procedures, dated 03/25, revealed, .3. Verify the physicians order, comparing the medication label to the MAR to verify the following: a. Right medication b. Right dosage c. Right route d. Right time e. Right resident .On 10/1/25 at 4:26 PM, during an observation, Licensed Practical Nurse (LPN) #1 prepared and administered medications to Resident #8 without reference to the MAR. The laptop on top of the medication cart displayed only the resident roster and not an individual MAR as LPN #1 prepared and administered medications.On 10/1/25 at 5:00 PM, during an interview, LPN #1 confirmed she prepared and administered medications for Resident #8 without use of the MAR. She stated she felt confident because she knew the residents' medications and reviewed the Twenty-Four (24)-Hour Report for new or changed physician orders.On 10/2/25 at 1:40 PM, during an interview, the Staff Development Coordinator stated that all licensed nurses received in-service training upon hire and at least annually regarding medication administration, including competency checkoffs. She stated the training required nurses to begin each medication pass by viewing the MAR to confirm physician orders and verify the five (5) rights of medication administration.On 10/2/25 at 2:55 PM, during an interview, the Director of Nursing (DON) stated it was not acceptable practice for nurses to go by memory or rely on the Twenty-Four (24)-Hour Report as a substitute for the MAR. The DON stated proper procedure required referencing each resident's MAR to confirm physician orders and ensure the five (5) rights of medication administration were followed for every resident. A record review of the admission Record revealed the facility admitted Resident #8 on 9/21/22 with current diagnoses including Type 2 Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/25 revealed Resident #8 had a Brief

Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.A record review of the Order Summary Report revealed Resident #8 had Physician's Orders for Warfarin Sodium 5 milligrams (mg), one (1) tablet by mouth every evening on Monday through Friday, dated 8/5/25 and Oxycodone/Acetaminophen 10-325 mg, one (1) tablet by mouth every six (6) hours for pain, dated 11/26/24.A record review of the electronic Medication Administration Record (eMAR) for October 2025 revealed LPN #1 documented the 1700 (5:00 PM) administration of Warfarin Sodium and the 1800 (6:00 PM) administration of Oxycodone/Acetaminophen on 10/1/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perry County Nursing Center

202 Bay Avenue West Richton, MS 39476

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

transfers using the sit-to-stand lift and stated she was not aware that residents who could not stand independently should be transferred into bed before incontinence care.On 10/2/2025 at 2:55 PM, during an interview, the DON stated her expectation was for staff to provide complete ADL care, including shaving, while honoring resident preferences. She confirmed male residents should be shaved during showers unless refused, and that shaving was part of personal hygiene. The DON stated nurses and management were responsible for supervising resident care. She confirmed that providing incontinence care while a resident was suspended in a sit-to-stand lift presented a risk and was inconsistent with standards of practice. She stated the purpose of the lift was for transfers only and that residents unable to stand unassisted should receive incontinence care in bed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perry County Nursing Center

202 Bay Avenue West Richton, MS 39476

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure respiratory medications were administered in accordance with manufacturer's instructions by not instructing

a resident to rinse the mouth following administration of an inhaled corticosteroid for one (1) of three (3) medication administrations reviewed, Resident #4. Findings included:A review of the facility's policy, Administration of Medications, revised 03/25, revealed, PURPOSE: To administer medications in accordance with best practice.A record review of the admission Record revealed the facility admitted Resident #4 on 6/10/25 with current diagnoses including Chronic Obstructive Pulmonary Disease (COPD).A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact.A record review of the Order Summary Report revealed Resident #4 had

a Physician's Order, dated 9/12/25 for Symbicort Inhalation Aerosol 80-4.5 micrograms (mcg)/ACT, two (2) puffs to be inhaled orally two (2) times daily, related to COPD.A record review of the Medication Administration Record (MAR) for October 2025 revealed Licensed Practical Nurse (LPN) #2 documented Symbicort Inhalation Aerosol for Resident #4 as administered on 10/2/25.A record review of the SYMBICORT 80/4.5 (budesonide 80 mcg and formoterol fumarate dihydrate 4.5 mcg) Inhalation Aerosol manufacturer's package insert, dated 07/2019 revealed, .WARNINGS AND PRECAUTIONS: Localized infections: Candida albicans infection of the mouth and throat may occur. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk.On 10/2/25 at 7:50 AM, during

an observation, Licensed Practical Nurse (LPN) #2 administered Symbicort, an oral inhalation medication, to Resident #4 and failed to instruct the resident to rinse his mouth following inhalation.On 10/2/25 at 7:56 AM, during an interview, LPN #2 confirmed she did not provide water or instruct Resident #4 to rinse his mouth after using the inhaler.On 10/2/25 at 2:55 PM, during an interview, the Director of Nursing (DON) stated that residents should be instructed and assisted as needed to rinse their mouths and spit out the water after administration of an oral inhaler to prevent the risk of thrush. She stated that the facility did not have a specific medication administration policy for oral inhalers and that nurses were expected to follow

the manufacturer's instructions provided with the medication.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet