Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy of treatment information for one (1) of sixteen (16) sampled residents (Resident #5), when a turning schedule was publicly posted in the resident's room. Findings included: A review of the facility's policy, Rights and Responsibilities of Residents, dated October 2023, revealed, .Resident rights which states 'residents are treated with dignity and respect which includes privacy in treatment and care for their personal needs .3. Procedure .F .will ensure that each resident admitted to the facility is .10. Treated with respect and full recognition of their dignity .including privacy in treatment and care . A record review of the Face Sheet revealed the facility admitted Resident #5 on 9/3/24 with diagnoses including Cerebral Palsy. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/25 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident's cognition was moderately impaired. On 4/21/25 at 12:53 PM, during an observation, Resident #5 was lying in bed, and a turning schedule was visibly posted at the head of the bed on the bulletin board, listing scheduled repositioning times. On 4/23/25 at 1:45 PM, during a follow-up observation, the turning schedule remained posted above the head of the bed in Resident #5's room. The schedule was affixed to the bulletin board located at the head of the bed, making it clearly visible to any person entering the resident's room. On 4/23/25 at 3:09 PM, during an interview and observation with Certified Nurse Aide (CNA) #3, she stated the turning schedule posted in Resident #5's room served as a reminder for staff to turn the resident every two (2) hours. The aide confirmed this practice was used routinely to prompt repositioning in accordance with the resident's care plan. On 4/23/25 at 3:36 PM, during an interview with the Certified Nursing Coordinator (CNC), she confirmed turning schedules were posted in resident rooms as visual reminders for Certified Nurse Aides (CNAs) to reposition residents every two hours or as needed based on care needs. Regarding Resident #5, the CNC stated there was a physician's order for side-to-side turning due to a pressure ulcer. She confirmed the order was documented in the medical chart, and the resident's family had not provided permission for the signage. On 4/23/25 at 4:08 PM, during an interview with the Nurse Supervisor, she stated the facility did not have a formal policy regarding the use of posted turning schedules in resident rooms. The schedules were used as reminders for CNAs to reposition residents every two (2) hours. She confirmed no families had given permission for use of these signs. On 4/24/25 at 2:09 PM, during an interview with the Director of Nursing (DON), she acknowledged her staff had informed her of the signage in Resident #5's room. She stated she had forgotten the signs were still in place and had not taken action to remove them. On 4/24/25 at 2:58 PM, during an interview with the Administrator, she acknowledged she was made aware there was posted signage in Resident #5's room indicating a schedule the staff were to turn the resident. She stated the facility's immediate plan included removal of all such signage, a review of applicable federal regulations, and provision of staff education. She further stated the facility planned to remove all signage containing clinical information regardless of format to ensure full compliance with privacy regulations.

Based on observation, interview, record review, and facility policy review, the facility failed to assess the risks associated with the use of bed rails, obtain resident consent, and conduct ongoing evaluations for continued use of bed rails for one (1) of one (1) resident reviewed for bed rail use, Resident #18. This failure had the potential to affect 40 of 63 residents residing in the facility who used side rails. Findings included: A review of the statement provided by the Administrator dated 4/24/25 revealed, There is currently no policy for bed rails . A review of the Siderails and Assist Device Owner's Manual for the bed type used for Resident #18 revealed, . A licensed healthcare provider should investigate the potential risk for entrapment on an individual basis . On 4/21/25 at 12:39 PM, Resident #18 was observed lying in bed with the head of the bed elevated. Half side rails were observed padded on both sides and were raised on the upper half of the bed. Resident #18 denied having any seizures and stated that the side rails had always been present since her admission, but she was not sure why they were in place. A record review of a list of current residents in the facility with side rails revealed 40 residents out of 63 had side rails as of 4/24/25. A record review of Resident #18's Face Sheet revealed the facility admitted the resident on 9/25/23 with diagnoses including Alzheimer's Disease. A record review of Resident #18's Physician Order Report revealed an order dated 9/25/23 for half-length padded side rails to aid with turning and positioning. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. A further review of Resident #18's medical record revealed no documented quarterly assessments for continued bed rail use and no signed consent for the bed rails. On 4/22/25 at 1:35 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained that most residents have side rails to assist with turning and repositioning. She denied that Resident #18 had any recent falls or seizures and reported that the resident had used side rails as long as she could remember. On 4/22/25 at 3:00 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that Resident #18 had used side rails for as long as she had worked at the facility. She was not sure why the bed rails were padded but confirmed the resident used them to assist with repositioning. On 4/23/25 at 3:40 PM, during an interview with the Administrator, she reported she was not aware of the regulations regarding bed rails. She confirmed the facility did not have signed resident consents for the use of bed rails and that residents had not been assessed for the risk of entrapment. On 4/24/25 at 10:10 AM, during an interview with the Director of Nursing (DON), she confirmed that Resident #18 had no signed consent for side rails and no assessment for the use of bed rails or entrapment risk. She reported that this was true for all residents with bed rails in the facility. She stated that because the rails were used as enablers and not restraints, they had not believed that consent or assessments were required. She confirmed Resident #18 had a physician's order for half-length padded bedrails for turning and positioning dated 9/25/23.

Based on observation, interview, and record review, the facility failed to ensure the safe maintenance and monitoring of bed rails in accordance with manufacturer guidelines for one (1) of one (1) resident observed with side rails, Resident #18, which resulted in the lack of required inspections and documentation for side rail safety with the potential to affect 40 of 63 residents who use side rails. Findings include: A record review of the facility's policy statement dated 4/24/25 revealed, There is currently no policy for bed rails. A review of the Siderails and Assist Device Owner's Manual for the bed type used for Resident #18 revealed, .Maintenance/Inspection Information: Visually inspect the assist handle and mounting bracket, and check for loose hardware on a monthly basis . A licensed healthcare provider should investigate the potential risk for entrapment on an individual basis . A record review of a list of current residents in the facility with side rails revealed that forty (40) out of sixty-three (63) residents had side rails as of 4/24/25. During an observation on 4/21/25 at 12:39 PM, Resident #18 was lying in bed with the head of the bed elevated. Half-length padded side rails were observed on both sides of the upper half of the bed. The resident denied any history of seizures and stated the side rails have just been that way and she did not know why, ever since she had been at the facility. During an interview on 4/23/25 at 10:10 AM, the Director of Nursing (DON) confirmed Resident #18 had half-length side rails on the bed. She reported being unaware of regulations and requirements related to side rail use. During an interview on 4/23/25 at 10:10 AM, the facility's Administrator reported the facility did not have any regular maintenance logs for bed rails. During an interview on 4/23/25 at 11:45 AM, the Maintenance Director confirmed he did not maintain any logs for bed rail inspections. He stated the facility had two (2) types of beds and that he was not aware maintenance logs or regular rounds were required by manufacturer guidelines. A record review of Resident #18's Face Sheet revealed the facility admitted the resident on 9/25/23 with diagnoses including Alzheimer's Disease. A record review of Resident #18's Physician Order Report revealed an order dated 9/25/23 for half-length padded side rails to aid with turning and positioning. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be treated with respect and dignity when a Certified Nurse Aide (CNA) would not provide assistance requested by the resident for one (1) of five (5) sampled residents. Resident #1. Findings included: A review of the facility's policy titled Rights and Responsibilities of Residents, revised October 2023, revealed, .It is the policy .to protect and support the fundamental human, civil, and constitutional rights of each resident .Procedure .F .ensure that each resident admitted to the facility is . (10) Treated with respect and full recognition of their dignity and individuality . A record review of the December 2024 Physician's Orders revealed Resident #1 had an order dated 11/7/2024, for one-person assistance with transfers, dressing, and bathing tasks to reduce the resident's risk of falls. A record review of the facility's investigation Vulnerable Adult Act, dated 11/11/2024 and completed on 11/15/2024, revealed that the facility received a complaint on 11/14/2024 regarding an incident involving Resident #1 and CNA #2 that occurred on 11/11/2024 between 8:00 PM and 10:00 PM. The report indicated Resident #1 pressed the call bell to request assistance with changing clothes and getting into bed. CNA #2 entered the room and reportedly refused to assist Resident #1 with the requested tasks, stating, I am only here to assist with toileting. CNA #2 was observed leaving Resident #1's room without providing the requested assistance. The report noted that Resident #1 was care-planned for staff assistance with transfers, toileting, dressing, and bathing to reduce fall risks. Section X of the facility's investigation confirmed the allegation indicating, The allegation is supported by a preponderance of the evidence . On 1/2/2025 at 10:15 AM, during an interview, Resident #1 recounted the incident. She stated she pressed her call bell and explained her needs to three CNAs who responded. CNA #2 informed her that only toileting assistance would be provided and refused to help her change clothes or get into bed. Resident #1 described CNA #2's demeanor as condescending and rude, though no foul language was used. Ultimately, another CNA assisted her with changing clothes and getting into bed. Resident #1 expressed dissatisfaction with CNA #2's behavior, calling it dismissive and unprofessional. On 1/2/2025 at 10:50 AM, during an interview, the CNA Supervisor #1 stated CNA #2 worked night shifts but was no longer employed at the facility. She described CNA #2 as a competent aide but noted prior instances of poor attitude toward co-workers. She emphasized that CNAs are responsible for providing safe and respectful care to residents and should not engage in disagreements with residents. She stated that CNAs must consult a nurse if they have questions about care. On 1/2/2025 at 12:30 PM, during an interview, the Nursing Home Administrator explained that the investigation into the 11/11/2024 incident revealed CNA #2 had refused to assist Resident #1 and may have been rude and disrespectful toward the resident. She stated that statements were collected by both her and the Director of Nursing (DON) and were forwarded to the facility investigator. The Administrator noted that CNA #2, a contract worker, was removed from the schedule pending the investigation but resigned on 11/14/2024 before the investigation concluded. A record review of the Face Sheet revealed the facility admitted Resident #1 on 8/23/2024, with current diagnoses including Heart Disease. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident with a new mental health diagnosis for one (1) of four (4) PASARRs reviewed. Resident #29. Findings include: A review of the facility's policy, Psychiatric Services: Statement of Purpose, revised January 2022, revealed, .Procedure (2) (a) When a resident receives a new mental health diagnosis, a change in status form will be completed by the Psychiatric NP and the Licensed Social Worker and submitted to Mississippi Preadmission Screening and Resident Review (PASRR) requesting a Level II Screening. Record review of the Face Sheet revealed the facility admitted Resident #29 on 8/03/17 with diagnoses that included Major Depressive Disorder and Anxiety Disorder. Record review of Resident #29's Diagnosis/History revealed the diagnosis of Bipolar II Disorder had an Onset date of 5/20/2019, and the diagnosis of Delusional Disorders had an Onset date of 9/16/2020 which were added after her admission date of 8/03/17. An interview on 1/10/2024 at 11:40 AM, with Social Worker #1, revealed when a resident has a psychiatric change in diagnoses, the facility receives the diagnosis change from the Psychiatric Nurse Practitioner. At that time, the facility should submit a PASRR Level II change in status request. An interview on 1/10/24 at 12:20 PM, with Social Worker #2, confirmed that Resident #29's last PASRR was completed on 2/13/2014 and she has had two (2) two additional mental health diagnoses, Bipolar II Disorder and Delusional Disorders, since then. She confirmed the facility failed to submit a Level II change in status request for the new mental health diagnoses. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/4/2023 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and facility policy review the facility failed to follow the care plan for one (1) of (14) care plans reviewed. Resident #28. Findings Include: Record review of the facility's policy, Interdisciplinary Care Plan, revision date August 2020, revealed 1. POLICY It is the policy of (Formal Name of Facility) to develop a written individualized care plan that meets the needs and choices of each resident as well as address the strengths, weakness, and goals identified by the resident's assessment,reassessment and results of diagnostic testing. The entire health record should be considered the Plan of Care. 2. PURPOSE The purpose of this policy is to establish measurable guidelines for using the assessments to develop a care plan that meets the resident's needs, choices and addresses their strengths, weaknesses and goals in order to enhance the quality of care provided. Resident #28 On 11/18/21 at 2:40 PM, in an observation of Resident #28, the State Agency (SA) entered resident's room as peri-care was being was being provided by Certified Nursing Assistant #1 (CNA) and assisted by CNA #2. The SA observed a pack of peri wipes lying directly on the bed with no barrier under the wipes. CNA #1 pulled wipes out of the packet and cleaned the resident's buttocks. CNA #1 asked CNA #2 to get the trash the can so she could dispose of the soiled wipes. CNA #2 retrieved a garbage can, while wearing gloves, and placed the garbage can beside the bed. CNA #2 did not remove her gloves and wash her hands after retrieving the garbage can. She returned to Resident #28's side and continued to hold the resident in place. Resident #28 was soiled with feces. CNA #2 pulled the resident over and her gloves became soiled with feces. CNA #2 removed her gloves and put on clean gloves but did not wash her hands. CNA #2 continued to assist CNA #1 by holding the resident in place for care. CNA #1 finished providing peri care to resident's buttocks and placed a clean brief on the resident and began to secure the brief. The SA asked CNA #2 if she had cleaned the vaginal area. CNA #1 then removed resident's brief from the front perineal area and began to wipe the resident's groin area. SA observed resident and noted feces was visible in the groin and vaginal area. CNA #1 did not wash hands or change gloves throughout the entire peri care observation. On 11/18/21 at 4:20 PM, in an interview with CNA #1, she confirmed when she wiped the vaginal and groin area, there was feces in the groin area. CNA #1 stated, I might not have wiped too good. I am supposed to wipe till I see the wipes are clean. CNA #1 said the resident can get an infection from her not changing gloves. She stated the resident can get a yeast infection or a Urinary Tract Infection (UTI) or something like that from the resident not getting good peri care. She stated she did not follow the care plan. On 11/18/21 at 4:35 PM, in an interview with CNA #2 confirmed there was feces on the wipes when CNA #1 wiped the groin area. She stated when she got feces on her gloves, she should have removed gloves, washed her hands, and put on clean gloves. She stated by her not changing gloves and washing her hands, the resident can get an infection and get sick. On 11/19/21 at 9:27 AM, in an interview with RN #3, Minimum Data Set (MDS)/Care Plan Nurse, she stated she wants staff to follow the care plan. She stated the care plan is a blueprint for the care that is to be provided to the resident and by staff not doing care correctly, it could cause the resident to get a UTI, skin breakdown, have discomfort, and in some cases, can cause severe harm to the resident. Record review of the Face Sheet revealed Resident #28 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease, Degenerative Disease of Nervous System, and Primary General Osteo (Arthritis). Record review of the Physician Orders for the month of November 2021 revealed an order with an order date of 6/25/21 to Check and change per protocol for incontinence - Keep clean and dry . Record review of the Care Plan with a Problem Onset date of 1/13/2021, revealed, Resident has potential for skin breakdown, infection, and pain .limited mobility, and incontinence of bowel and bladder. The care plan goal revealed Resident will have no skin breakdown nor infection with multiple protective measures . Care plan approaches included .Check and change per protocol for incontinence-keep clean and dry . Record review of the Quarterly MDS with a Assessment Reference Date (ARD) of 9/20/21, Section C revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #28 was not able to complete the interview. A review of Section G revealed the resident is totally dependent on staff for toilet use and personal hygiene and Section H revealed the resident is always incontinence of bowel and bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the possible spread of infection during incontinent care for one (1) of five (5) incontinent care observations. Resident #28. Findings Include: Record review of the facility's policy, Hand Hygiene, with a revision date of March 2021, revealed 1. POLICY It is the policy of (Formal Name of Facility) that employees will use proper hand hygiene techniques to prevent the spread of infectious diseases .PROCEDURE 3. C. Employees must always wash hands: .(8) after removing gloves. (9) After touching objects that may be contaminated with disease causing microorganisms Record review of the facility's policy, Infection Prevention Statement of Purpose, with a Reauthorized date of September 2021, revealed 1. POLICY It is the policy of (formal Name of Facility) to provide comprehensive infection prevention services aimed at surveillance, prevention and control of infections to all Individuals Receiving Services (IRS)/residents, employees, and visitors while always striving to improve quality of care . Record review of the facility's policy, Incontinence Perineal Care with a revised date of October 2020 revealed 1. POLICY It is the policy of (Formal Name of Facility) to provide incontinence/perineal care every two hours and as soiling occurs .3. D. Clean the surface where barrier will be placed with hospital approved disinfectant per manufacturer's recommendations. Apply barrier to surface .G. Female: Starting at the front of the perineal area, wash genital area, moving front to back, separate labia and wash all skin folds . On 11/18/21 at 2:40 PM, in an observation of Resident #28, the State Agency (SA) entered resident's room as peri-care was being was being provided by Certified Nursing Assistant #1 (CNA) and assisted by CNA #2. The SA observed a pack of peri wipes lying directly on the bed with no barrier under the wipes. CNA #1 pulled wipes out of the packet and cleaned the resident's buttocks. CNA #1 asked CNA #2 to get the trash the can so she could dispose of the soiled wipes. CNA #2 retrieved a garbage can, while wearing gloves, and placed the garbage can beside the bed. CNA #2 did not remove her gloves and wash her hands after retrieving the garbage can. She returned to Resident #28's side and continued to hold the resident in place. Resident #28 was soiled with feces. CNA #2 pulled the resident over and her gloves became soiled with feces. CNA #2 removed her gloves and put on clean gloves but did not wash her hands. CNA #2 continued to assist CNA #1 by holding the resident in place for care. CNA #1 finished providing peri care to resident's buttocks and placed a clean brief on the resident and began to secure the brief. The SA asked CNA #2 if she had cleaned the vaginal area. CNA #1 then removed resident's brief from the front perineal area and began to wipe the resident's groin area. SA observed resident and noted feces was visible in the groin and vaginal area. CNA #1 did not wash hand or change gloves throughout the entire peri care observation. On 11/18/21 at 4:20 PM, in an interview with CNA #1, she stated she should have had a barrier in place and that she should have gathered all supplies and put them on a barrier before starting care. She stated the wipes are not supposed to be on the table and not on the bed. She confirmed she should have had the garbage can by the bed and she should have removed her gloves after cleaning the buttocks, washed her hands, and applied clean gloves. She stated she guessed she was not thinking while providing peri care. CNA #1 admitted the resident can get a Urinary Tract Infection (UTI) from not changing gloves and a yeast infection or something like that from resident not getting good peri care. She confirmed when she wiped the vaginal and groin area, there was feces in the groin area. CNA #1 stated, I might not have wiped too good and I am supposed to wipe till I see wipes are clean. CNA #1 said the resident can get an Urinary Tract Infection (UTI) from her not changing gloves. She stated the resident can get a yeast infection or something like that from the resident not getting good peri care. On 11/18/21 at 4:35 PM, in an interview with CNA #2, she stated the CNA's were supposed to have all items on a barrier. She also stated when she gave CNA #1 the garbage can, she did not think about removing her gloves and washing hands. She confirmed that she changed her gloves, but did not wash her hands. She stated when she got feces on her gloves, she should have removed her gloves, washed her hands, and put on clean gloves. She confirmed that by not changing her gloves and washing her hands the resident could get an infection. She confirmed there was feces on the wipes when CNA #1 wiped the groin area. On 11/18/21 at 4:55 PM, in an interview with Registered Nurse #2 (RN)/ Infection Control Nurse, she stated the CNAs placed the resident at risk for infection by placing the pack of wipes on the bed and not providing a barrier. She stated CNA #2 should have washed hands and applied clean gloves after moving the garbage can. She confirmed the actions of the CNAs could cause the resident to get an UTI or have skin breakdown from not being clean properly. RN #2 confirmed she is responsible for CNA skill check-offs. She stated she completed the skills check-off in October. She stated she completes peri care audits monthly and watches the CNAs provide care to the residents monthly. On 11/18/21 at 5:16 PM, in an interview with Director of Nursing (DON), she stated the CNAs are supposed to have a barrier set up before starting care. and not having a barrier is an infection risk for the resident. She confirmed that CNA #2 should have removed her gloves, washed her hands, and put on clean gloves after she moved the garbage can. She stated by CNA #2 not changing her gloves, the resident can get an infection. She also stated that by CNA #2 not cleaning the resident properly, it could cause the resident to get an UTI or skin breakdown. The DON confirmed that CNA #1 should have changed her gloves if they were visibly soiled. She stated the CNA should have put down barrier, and pulled all wipes needed out of the pack before starting care and that pulling wipes out pack while cleaning the resident is an infection control issue. On 11/19/21 at 9:27 AM, in an interview with RN #3 Minimum Data Set (MDS)/Care Plan Nurse, she stated by staff not doing care correctly, it could cause the resident to get a UTI, skin breakdown, or have discomfort. On 11/19/21 at 9:32 AM, in an interview with RN #1/Professional Development Nurse/Nurse Educator, she stated the CNAs knew better. She confirmed the CNAs should have had a barrier in place and their actions could cause the resident to have skin breakdown, dignity issues, infection, skin integrity issues and discomfort. Record review of the Face Sheet revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Degenerative Disease of Nervous System, Primary General (osteo) Arthritis. Record review of the Physician Orders for the month of November 2021 revealed an order with an order date of 6/25/21 to Check and change per protocol for incontinence - Keep clean and dry . Record review of the Quarterly MDS with a Assessment Reference Date (ARD) of 9/20/21, Section C revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #28 was unable to complete the interview. A review of Section G revealed the resident is totally dependent on staff for toilet use and personal hygiene and Section H revealed the resident is always incontinence of bowel and bladder. Record review of a Staff Development Program Record with the Title of Program listed as Infection Prevention: Focus on Perineal Care dated 10/21/21, revealed CNA #1's signature which confirmed she attended the training. Record review of CNA Annual Competency Check-Off List dated 4/22/21, revealed CNA #1's initials onIncontinent/Perineal Care and Infection Prevention. Record review of CNA Annual Competency Check-Off List dated 8/25/21, revealed CNA #2's initials onIncontinent/Perineal Care and Infection Prevention. Record review of CNA Skills Checklist dated 8/25/21 .SKILL . Male and Female Pericare/Incontinent Care revealed CNA #1's signature dated 4/21/21 and initials under the met column.