Windsor House

Inspectors wroteBased on interviews, record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #s 1, 2, and 4 were free from abuse. 1) On [DATE], Employee Identifier (EI) #4, a CNA (Certified Nursing Assistant) and EI #5, a CNA were providing care for RI #2. During the care RI #2 had gotten feces on his/her hands and was trying to touch EI #4. EI #5 witnessed EI #4 telling RI #2 not to touch her, and that RI #2 was nasty. EI #5 said, EI #4 held RI #2's hands down pinning RI #2's arms down by his/her head and said, don't fucking touch me. The witness (EI #5) said RI #2 stated ok I'm sorry but you're hurting me. [...]

Inspectors wroteBased on interviews, medical record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of Facility Reported Incidents (FRIs) received by the State Survey Agency, the facility failed to implement the facility's abuse policies when: 1) Employee Identifier (EI) #8, Licensed Practical Nurse (LPN), Unit Manager failed to report an allegation of sexual abuse to the Administrator and failed to implement immediate protective measures. On 07/28/2023 Resident Identifier (RI) #6's daughter reported to EI #8 that RI #7 had entered RI #6's room and touched his/her breast twice. [...]

Inspectors wroteBased on interviews, record review and review of a facility policy titled Change of Resident Room/Roommate, the facility failed to notify Resident identifier (RI) #7's representative when RI #7 was transferred to a different room on 07/28/2023. This deficient practice affected RI #7, one of two residents sampled for notification.

Inspectors wroteBased on interviews, record review and review of a facility policy titled Means of Egress, the facility failed to maintain an environment that was free of accident hazardous. Resident Identifier (RI) #7, a resident with a history of wandering in and out of other resident's room, began to exhibit more frequent wandering behaviors, and on 07/28/2023, facility staff built a barricade across the hallway to prevent the resident from wandering. This affected RI #7, one of three sampled residents care planned for wandering, and had the potential to affect all residents residing in Room locators (RL) 2-5.

Inspectors wroteBased on interview and review of Resident Identifier (RI) #7's medical record, the facility failed to identify and address the behavioral health care needs of RI #7, a resident with repeated incidents of wandering. In addition, the facility further failed to ensure their Behavioral Assessment policy/procedure was followed to direct the staff on how to assess the resident behaviors, utilizing the Behavioral Assessment Tool to help determine the factors contributing to identified behavior problems. The facility also did not identify specific behavioral interventions for RI #7, to deal effectively with the situation of wandering, after it was document, the resident continued to wander in/out other residents' rooms. This deficient practice affected RI #7; one of three sampled residents reviewed for wandering behaviors.

Inspectors wroteBased on interviews, record review, and review of a facility policy titled Weight Loss Interventions, the facility failed to notify Resident Identifier (RI) #36's responsible party when RI #36, a resident with a history of weight loss, lost a severe amount of weight from October 2020 through March 2021. RI #36 went from 169.9 pounds to 132.0 pounds without the family being made aware of the continued weight loss. This deficient practice affected RI #36; one of three residents sampled for weight loss.

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #36's medical record, and the facility's policy titled Weight Loss Interventions, the facility failed to ensure nutritional interventions were implemented when RI #36 experienced a severe weight loss from November 2020 to January 2021. Beginning 11/25/2020, RI #36 experienced a severe weight loss of 7.3% in one month. There were no nutritional interventions to address the resident's weight loss until 1/18/2021. This deficient practice affected RI #36; one of three residents reviewed for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of bed-hold to the resident and/or their representative when Resident Identifier (RI) #59 and RI #78 were transferred to the local hospital. This deficient practice affected RI #59 and RI #78, two of three sampled residents reviewed for hospitalization, with the potential to affect all residents that are transferred to the hospital.

Inspectors wroteBased on interview, review of Resident Identifier (RI) #36's medical record and the facility's policy titled Weight Loss Interventions, the facility failed to consistently document the meal intake of RI #36, a resident with a history of weight loss. This deficient practice affected RI #36; one of three residents reviewed for weight loss.

Inspectors wroteBased on observation, interviews and review of Resident Identifier (RI) #28's medical record, the facility failed to maintain the ceiling in RI #28's room. RI #28's ceiling was observed with different color paint and water spots. This deficient practice affected RI #28, one of 39 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident Identifier (RI) #77's Quarterly Minimum Data Set (MDS) with an assessment reference date of 10/21/2020, accurately reflected the stage of RI #77's pressure ulcer. This deficient practice affected RI #77; one of 14 residents whose MDS assessments were reviewed.

Inspectors wroteBased on an observation, interviews, record review, and review of FUNDAMENTALS OF NURSING, the facility failed to ensure a dressing remained on Resident Identifier (RI) #77's Stage IV sacral pressure ulcer as ordered by the physician. This deficient practice affected RI #77; one of two residents observed for wound care.

Inspectors wroteBased on interview, review of Resident Identifier (RI) #59's medical record and the facility's Diversicare Restorative Guideline, the facility failed to assess RI #59, a resident having occasional incontinent episodes of bladder; and a history of falls when going to and from the bathroom, for a toileting program. This deficient practice affected RI #59; one of two residents reviewed for bowel and bladder incontinence.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to discard the expired Lantus pen of Resident Identifer (RI) #67 and further failed to label and date the inhaler for RI #68. These deficient practices affected RI #67 and RI #68, and were oberved on one of two medication carts in the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct an investigation when Resident Identifier (RI) #36, an ambulatory cognitively impaired resident brought an implant/bridge to a licensed nurse on 10/20/2020. The facility failed to conduct an investigation to determine whose implant/bridge this was. This deficient practice had the potential to affect one of the 82 residents who reside at the facility.

Inspectors wroteBased on observation and interviews, the facility failed to ensure Employee Identifier (EI) #10, a Nursing Assistant (NA), changed her contaminated gloves during the provision of incontinence care for Resident Identifier (RI) #77. This deficient practice affected RI #77; one of one resident observed for incontinence care.

Inspectors wroteBased on an observation, interviews, review of medical records, and review of a facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure Resident Identifier (RI) #72's Injury of Unknown Source was reported to the State Agency within twenty-four hours. This affected 1 of 19 sampled residents observed for signs of abuse during the survey. Findings Include: RI # 72 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction of Right Middle Cerebral Artery, Muscle Weakness, Difficulty in Walking, Hemiplegia and Hemiparesis following Cerebral Infarction, affecting left side, History of Falls, Unspecified Dementia without Behavioral Disturbance, and Hypertension. RI #72's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 2/17/19, documented RI #72 had severe cognitive impairment. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to ensure Resident Identifier (RI) #15 and RI #75 were invited to care plan meetings on 3-5-18 and 3-27-18. This affected two of 23 sampled residents. Findings Include: 1) RI #15 was admitted to the facility on [DATE]. A review of RI #15's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3-2-18 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated he/she was cognitively intact. On 4-4-18 at 5:30 p.m., during an interview, RI #15 stated he/she was unaware of a care plan meeting. An interview was conducted with Employee Identifier (EI) #1, Registered Nurse, on 4-5-18 at 1:42 p.m. EI #1 was asked if RI #15 was invited to the care plan meeting on 3-5-18. EI #1 stated, no. EI #1 was asked if RI #15 should have been invited to the care plan meeting. [...]

Inspectors wroteBased on observation, interview, medical record review, and a review of [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse administered insulin in a subcutaneous (under the skin) area of Resident Identifier (RI) #21's body. This affected Resident Identifier RI #21, one of four residents observed during medication administration. Findings Include: A review of [NAME] and Perry's FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 32, page 647 and 648, revealed: . Subcutaneous injections involve placing medications into the loose connective tissue under the dermis. The best subcutaneous injection sites include the outer posterior aspect of the upper arms, the abdomen from below the coastal margins to the iliac crests, and the anterior aspects of the thighs. [...]

Inspectors wroteBased on observation, interviews, medical record review, and [NAME] AND PERRYS, FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse did not blow on the glucometer or the multi-dose insulin pen before placing them into the medication cart. This affected Resident Identifier (RI) #21, one of four residents observed during medication administration and one of three nurses observed for medication administration. Findings Include: A review of [NAME] and Perry's, FUNDAMENTALS OF NURSING, Ninth Edition, Chapter 29, page 445, revealed: . Equipment used within the environment .often becomes a source for the transmission of pathogens. Box 29-1 Modes of Transmission . [...]