Windsor Care Center

F-F880, from the last survey, were performed for at least three months. She stated she no longer performed audits of cleaning shared equipment and hand hygiene. She stated it was her expectation that staff follow policies and procedures to keep infections down. She stated it was her expectation that all the appropriate people attended QAPI meetings for QAPI to be successful.

During an interview on 03/13/2025 at 4:23 PM with the Administrator, he stated quality assurance meetings were held every day. He stated during those meetings, if a process was not successful, then adjustments were made to improve it. The Administrator stated he maintained oversight of QAPI. He stated shared equipment should be cleaned and disinfected to prevent infection and any kind of cross contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 185242 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185242 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Care Center 125 Sterling Way Mount Sterling, KY 40353

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50442 potential for actual harm Based on observation, interview, record review, and review of the facility's policies, the facility failed to Residents Affected - Some establish or maintain an effective infection prevention and control program, which was essential for providing

a safe, sanitary, and comfortable environment while preventing the development and spread of infectious diseases for 5 of 50 sampled residents, Resident (R) 30, Resident R17, Resident R74, F90, and Resident R325.

1. Observation on 03/11/2025 and 03/12/2025 revealed Resident R30's oxygen nasal cannula tubing was dated 02/18/2025, and the humidification water bottle was undated.

2. Observation on 03/11/2025 revealed State Registered Nurse Aide (SRNA) 3 and SRNA5 were seen not hand sanitizing between passing lunch trays for Resident R17, Resident R74, and Resident R90. Further observation on 03/12/2025 revealed SRNA13 touched Resident R90's food with no gloves on and hand hygiene not performed.

3. Observation on 03/12/2025 revealed SRNA8 and SRNA7 entered Resident R325's room, who was on droplet precautions, performed resident care, then exited the room with the used, uncleaned gait belt, and SRNA7 put it in her pant pocket.

4. Observation on 03/12/2025 of Resident R30's wound care revealed Licensed Practical Nurse ( LPN) 1 did not sanitize hands between changing gloves.

5. Observation on 03/13/2025 at 9:45 AM of laundry services revealed gowns were not worn in the laundry while staff handled dirty or soiled linens.

The findings include:

Review of the facility's policy titled, Hand Hygiene, not dated, revealed all staff would perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility. Per the policy's attachment, hand hygiene via either with soap and water or with alcohol based hand rub should be performed before and after applying personal protective equipment (PPE) such as gloves, before and after handling clean or soiled dressings, linens, etc., and during resident care when moving from a contaminated body site to a clean body site. Additional review revealed

the use of gloves did not replace hand hygiene, and if the task required gloves, perform hand hygiene prior to donning (putting on) gloves and immediately after removing gloves.

Review of the facility's policy titled, Oxygen Administration, revealed staff should change tubing weekly and as needed if it became soiled or contaminated for infection prevention purposes.

Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, undated, revealed resident care equipment can be a source of indirect transmission of pathogens. The policy also stated that each user is responsible for routine cleaning and disinfection of multi resident items after each use, particularly before use for another resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 185242 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185242 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Care Center 125 Sterling Way Mount Sterling, KY 40353

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 0880 Review of the facility's policy titled, Personal Protective Equipment [PPE], undated, revealed, This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to Level of Harm - Minimal harm or residents, visitors, and other staff. The policy also stated, All staff who have contact with resident and/or their potential for actual harm environments must wear PPE equipment as appropriate during resident care and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Residents Affected - Some

Review of the facility's policy titled, Laundry, undated, revealed staff shall consider all previously worn clothing and used linens as potentially contaminated, and laundry staff will be in-serviced to handling linens and laundry on a regular basis.

1. Observation of Resident R30 on 03/11/2025 at 9:32 AM and 03/12/2025 at 11:59 AM revealed she had on oxygen being administered via nasal cannula. Further observation of Resident R30's oxygen concentrator revealed it was hooked to a humidification bottle that was full of water. There was no date on the bottle. The oxygen tubing was dated 02/18/2025. Observation could not be done on 03/13/2025 because Resident R30 was hospitalized on [DATE REDACTED].

Review of Resident R30's Treatment Administration Record revealed that in January 2025 and February 2025 oxygen tubing was changed weekly on Tuesdays, except for 02/18/2025, which was not marked off. Review of the month of March had both Tuesdays marked for the changing of the tubing.

In an interview on 03/12/2025 at 2:35 PM with LPN1, she stated oxygen tubing and the humidification water bottle for administration of oxygen via nasal cannula were changed weekly, on Tuesday evenings. She stated both should be dated the date they were changed. She stated they should be changed to prevent infections.

In an interview on 03/13/2025 at 8:11 AM with the Infection Prevention (IP) Nurse, she stated oxygen tubing was changed weekly, and the humidification bottles should be changed when empty or when the oxygen tubing to administer oxygen via nasal cannula was changed. She stated both were to be labeled with the date they were changed. The IP Nurse stated oxygen tubing that was not changed was a source of infection because of bacterial growth.

In an interview on 03/13/2025 at 8:18 AM with the Director of Nursing (DON), she stated oxygen tubing and

the humidification water bottle should be changed weekly. She stated some individuals that were on continuous high levels of oxygen might need their humidification water bottle changed more frequently, as it might run dry more frequently. She stated that an issue that could result from oxygen tubing dated 2/18/2025 observed on 03/12/2025 and 03/13/2025 still in use would be the user could get a respiratory infection.

In an interview on 03/13/2025 at 8:35 AM with the Administrator, he stated oxygen tubing and humidification water bottles needed to be changed weekly or if soiled. He stated both should be dated when changed. He stated an issue that could result from oxygen tubing being used longer than a week could be an infection.

2. On 03/11/2025 at 12:23 PM during observation of the lunch service, two State Registered Nurse Aides (SRNA) 3 and SRNA5, were seen not hand sanitizing between distributing trays for Resident R17, Resident R74, and Resident R90. Further observation on 03/12/2025 at 12:22 PM revealed SRNA13 touched Resident R90's food with no gloves on and hand hygiene not performed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 185242 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185242 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Care Center 125 Sterling Way Mount Sterling, KY 40353

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 0880 In interviews with both SRNA3 and SRNA5 on 03/11/2025 at 12:40 PM and 12:35 PM respectively, both stated hand hygiene should be performed between each delivered tray, either using alcohol-based hand gel Level of Harm - Minimal harm or or washing hands with soap and water. potential for actual harm

In an interview on 03/13/2025 at 8:11 AM with the IP Nurse, she stated staff should hand sanitize between Residents Affected - Some each tray with the alcohol-based hand gel and wash their hands with soap and water after every third tray delivered. She stated if a resident's food was touched, the staff member should wear gloves.

In an interview on 03/13/2025 at 8:18 AM with the DON, she stated staff should hand sanitize between each resident's tray with alcohol-based hand gel and wash their hands with soap and water after every third tray delivered or when soiled.

In an interview on 03/13/2025 at 8:35 AM with the Administrator, he stated his expectation was that staff should keep their hands clean and not touch the food when distributing meal trays to the residents. He stated if a staff member needed to touch a resident's food, they should wear gloves. He stated hand hygiene should be performed between each tray and when visibly soiled.

3. Observation on 03/12/2025 at 9:21 AM revealed SRNA8 and SRNA7 entered Resident R325's room, who was on droplet precautions, performed resident care, then exited the room with the used, uncleaned gait belt placed

in SRNA7's pant pocket.

Review of Resident R325's Admission Record revealed the facility admitted Resident R325 on 03/11/2025 with a diagnosis of influenza.

Review of the facility's list of Residents on Isolation Precautions, provided by the facility, listed 19 residents, including Resident R325, who was on Droplet Precautions for influenza.

During an interview on 03/11/2025 at 12:13 PM with SRNA3, she stated she carried her gait belt around her waist, and each SRNA had their own. She stated she did not clean her gait belt between each resident use.

During an interview on 03/11/2025 at 12:15 PM with SRNA4, she stated she had her own gait belt, and she washed it at her house after her shifts. She stated during her shift, between resident use, she used an antibacterial spray provided by the janitor. She stated gait belts were part of their uniform, and they must keep them on person while working.

During an interview on 03/11/2025 at 12:17 PM with SRNA5, she stated she sanitized her gait belt with sani-wipes (a disinfectant) between each use. She stated the wipes were kept at the nurses' stations, and it was important not to spread germs.

During an interview on 03/12/2025 at 9:21 AM with SRNA8, she stated she had used her gait belt on Resident R325 while in the room and placed it in her pocket when she was finished using it, prior to cleaning it. She stated

she was going to clean it with sani-wipes that were at the nurses' station. She stated once she cleaned it,

she usually placed it back into her pocket.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 185242 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185242 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Care Center 125 Sterling Way Mount Sterling, KY 40353

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 0880 During an interview on 03/12/2025 at 9:21 AM with SRNA7, she stated she kept her gait belt around her waist, and it was important not to place a dirty shared equipment and a clean shared equipment in the same Level of Harm - Minimal harm or place to prevent the spread of infection. potential for actual harm

During an interview on 03/12/2025 at 10:05 AM with the IP Nurse, she stated we've done a lot of verbal and Residents Affected - Some hands on education regarding cleaning shared equipment because the facility had gone through this on the last survey. She stated SRNAs were expected to keep gait belts on them, and they were expected to clean them with sani-wipes after each use. She stated this was important so infections were not transmitted from one person to another.

4. Observation on 03/12/2025 at 12:05 PM of Resident R30's wound care performed by LPN1 revealed she hand sanitized and put on gloves prior to cleaning Resident R30's pressure ulcer with normal saline. LPN1 then removed her gloves and placed on a new pair without performing hand hygiene. She rubbed the zinc cream onto Resident R30's pressure ulcer with her gloved hand and then removed the gloves. Once again, she did not perform hand hygiene prior to placing on a new pair of gloves. Instead, she began to rub the zinc cream on various open sores on Resident R30's hip, abdomen, and shoulder without changing gloves between sites and without washing her hands.

In an interview with LPN1 on 03/12/2025 at 12:23 PM, she stated hand hygiene should be done prior to, during, and throughout wound care. When asked if hand hygiene should be performed between each glove change, LPN1 stated yes. LPN1 stated she should have used hand sanitizer each time she changed her gloves, but there was not any in the room, so she did not. LPN1 stated she should have changed gloves when placing zinc cream on different parts of Resident R30's body to prevent contamination of the wounds.

In an interview with Unit Manager/Registered Nurse (RN) 1 on 03/12/2025 at 1:59 PM, she stated staff should hand sanitize and change gloves before and after resident care.

In an interview on 03/13/2025 at 8:11 AM with the IP Nurse, she stated it was her expectation that staff hand sanitized or washed their hands before and after putting on or taking off gloves.

In an interview on 03/13/2025 at 8:18 AM with the DON, she stated her expectation was that hands should be washed or alcohol-based hand gel should be used every time a staff member changed gloves, in addition to prior to and after resident care.

In an interview on 03/13/2025 at 8:35 AM with the Administrator, he stated hand hygiene should be performed between glove changes.

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5. Observation on 03/13/2025 at 9:45 AM of laundry services revealed gowns were not worn while handling dirty or soiled linens.

During an interview on 03/12/2025 at 9:45 AM with the Environmental Supervisor, he stated exam gloves were used while handling dirty laundry, but gowns were only used for laundry from COVID rooms. He stated gowns were not worn otherwise. He stated he did not know what the facility policy stated regarding PPE and dirty linens.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 185242 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185242 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Care Center 125 Sterling Way Mount Sterling, KY 40353

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 0880 During an interview on 03/12/2025 at 9:45 AM with the Laundry and Housekeeping Supervisor, she stated only gloves were worn when handling soiled/dirty laundry, and gowns were only worn when linens were from Level of Harm - Minimal harm or a COVID positive room. She stated she was not aware of what the facility policy stated regarding PPE and potential for actual harm dirty linens.

Residents Affected - Some During an interview on 03/13/2025 at 10:45 AM with the DON, she stated it was her expectation that staff follow policies and procedure to keep infections down.

During an interview on 03/13/2025 at 4:23 PM with the Administrator, he stated his expectation was that staff properly cleaned shared equipment between resident use to prevent infection and any kind of cross contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 185242