Windham House Of Hattiesburg

Based on observations, interviews, record reviews, and policy reviews, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety, including expired foods, exposed foods, overly ripe produce, unsanitary practices by staff, and incomplete temperature logs for resident refrigerators for three (3) of (3) days of survey. Findings included: A review of the facility's policy titled Food Storage Labeling, revised 05/18, revealed, Policy: The facility will ensure the safety and qualify of food by following good storage and labeling procedures .Procedure: 1. Labeling a. All temperature controlled foods .will be labeled. 3. Rotations b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed their manufacturer use-by date or expiration date . A review of the facility's policy titled Employee Work Practices, revised 05/2018, revealed, Food service employees shall follow sanitary practices to prevent the spread of foodborne illness . Wears a . hair restraint (e.g., beard restraint)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident receiving dialysis for one (1) of one (1) dialysis residents reviewed. (Resident #10) Findings included: A review of the facility's policy Resident Assessment, revised 09/19, revealed, An assessment will be completed on each resident utilizing the MDS . The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident-specific issues . The assessment will describe the resident's physical and mental deficits, strengths and the requirements of assistance to meet their needs . A record review of the Order Listing Report revealed Resident #10 had a Physician's Order, dated 7/27/24, for dialysis services at a local clinic every Monday, Wednesday, and Friday. A record review of the admission Record revealed the facility originally admitted Resident #10 on 4/26/2022 and with diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis. A record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to protect a resident's right to a dignified existence by posting clinical data on a resident board in open view for one (1) of 15 sampled residents. (Resident #36). Findings included: A review of the facility's Resident Rights Policy, reviewed 12/23, revealed Every resident in the facility has the right to .16. Have their personal and medical records treated as confidential . A review of the facility's policy titled Dignity and Respect, revised 07/22, revealed A facility must treat each resident with respect and dignity .The facility shall protect and promote the rights of the resident . A record review of the admission Record revealed the facility admitted Resident #36 on 07/19/2022 with diagnoses including Cerebral Infarction. During an observation and interview on 11/12/24 at 10:02 AM, there was identifiable care information visible on a board at the head of the bed in Resident #36's room. The documentation included the resident's name, turn rotation schedule, and care coordination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the resident's right to a clean, comfortable home-like environment as evidenced by a stained privacy curtain, undusted high-touch areas, scuffed and dirty walls, and an unclean shower in the room of one (1) of 15 sampled residents. (Resident #18) Findings included: A review of the facility's policy Resident Environment, dated 09/15, revealed, It is the policy of this facility to provide a safe, clean, comfortable, homelike environment . On 11/12/2024 at 1:16 PM, during an observation and interview, Resident #18's shower contained a hair wash basin and a dead house plant, with grime and dirt visible on the shower floor. The room had noticeable dust and spider webs above the overhead light, and grime and scuff marks were observed on the wall behind the headboard. The privacy curtain at the sliding glass door displayed oil and dirt stains. Resident #18, the sole occupant of the room, stated that she had never used the shower, noting that it had been grimy for over six (6) months.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a resident's comprehensive care plan regarding Enhanced Barrier Precautions (EBP) while providing Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of 15 sampled residents. Resident #19. Findings included: A record review of the facility's policy Care Plan Process, revised 08/17, revealed, . CAA's (Care Area Assessments) assist in guiding to develop an individualized plan of care and should provide structure for the care and services that are needed . When implemented properly, the CAA process should help staff: . address the need and desire for other important considerations . The comprehensive care plan is an interdisciplinary tool . for the care of the resident . A record review of Resident #19's Care Plan revealed Problem/Need: Resident has a feeding tube .Approaches .Enhanced barrier precautions-Gown and gloves to be worn during high contact resident care activities (dressing, bathing, transfers, changing linens, hygiene, and toileting . The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee as evidenced by one (1) of (1) re-cited deficiency originally cited in April 2023 on an annual recertification survey. Findings Include: A review of the facility's, QAPI Governance and Leadership Guidelines', revised 08/15, revealed, Oversight of the facilities QAPI program is provided through the Quality Assessment and Assurance (QA Committee) .The QAPI program is developed and led by the QA Committee, but requires input and participation from staff, residents and families .Element 5: Systematic Analysis and Systemic Action .The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/structured approach to determine whether and how identify problems may be caused or exacerbated by the way care and services are organized or delivered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review and facility policy review the facility failed to implement Enhanced Barrier Precautions (EBP) for one (1) of three (3) residents reviewed as high risk for acquiring multi-drug-resistant organisms (MDROs). (Resident #19) Findings included: A record review of the facility's policy Enhanced Barrier Precautions, revised 03/24, revealed, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies . On 11/13/2024 at 10:15 AM, during an interview, Registered Nurse (RN) #1 explained that she was aware Resident #19 was on EBP due to having a PEG tube. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect anticoagulant therapy and a nephrostomy tube for two (2) of 15 sampled residents. Resident #10 and Resident #18 Findings include: A review of the facility's policy Resident Assessment with the latest revision date of 09/19 revealed An Assessment will be completed on each resident utilizing the MDS. The reason for assessment, schedule, and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual .Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the .assessment . Resident #10 On 04/25/23 at 12:12 PM, during an interview with Resident #10, she stated that she is on Pletal (a medication to prevent platelets from sticking together and forming a blood clot). Record review of the Face Sheet revealed Resident #10 was admitted to the facility on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility policy review, the facility failed to ensure a Pre-admission Screening (PAS) accurately reflected a diagnosis of a major mental illness for one (1) of 16 record reviewed. Resident #6 Findings include: A review of the facility's policy, Pre-admission Screening PAS/PASRR (MS (Mississippi) Only) revealed, Anyone applying for admission into a nursing facility must be approved prior to the admission .The PAS with level 1 PASRR (Pre-admission Screening and Resident Review) must be submitted .and approved prior to admission to a nursing facility . A record review of the Face Sheet revealed the facility admitted Resident #6 on 05/06/21 and she had a diagnosis of Schizoaffective Disorder, Bipolar Type. A record review of the Pre-admission Screening (PAS) Application for Long Term Care, dated 05/06/2021, revealed B Level II Referral was marked to indicate Resident #6 did not have a diagnosis of a major mental illness. A review of the resident's preadmission records provided by the facility revealed Resident #6 was admitted from another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.