Winona Manor Health Care And Rehabilitation Center

F-F726

Review of the facility policy titled Infection Prevention and Control Program with a revision date of 10/2018 revealed under, Policy Statement: An infection prevention and control program (IPCP) Is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Review of the facility policy titled, Enhanced Barrier Precautions, with an effective date of 9/01/22, revealed

the following: Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high-contact resident care activities . High-contact care activities provide opportunities for the transfer of MDROs to staff hands and clothing . High-contact care activities include: feeding tube care, wound care .

Record review of facility's letterhead revealed, This facility does not have a policy on storage of a biliary tube bag.

Resident #11

During an observation and interview on 3/26/25 at 10:35 AM, the Wound Care Registered Nurse (RN) and Certified Nursing Assistant (CNA) #5 performed wound care for Resident #11. The RN performed the wound treatment on the resident's sacral area and CNA #5 assisted. Neither staff used enhanced barrier precautions (EBP) during the wound care procedure.

During an interview on 3/27/25 at 8:15 AM, the Wound Care RN revealed she was unaware of the EBP guidelines and did not dress out during her wound care treatments. She stated she had now been in-serviced on EBP and the purpose to decrease the risk for infection.

Record review of Resident #11's Admission Record revealed the facility admitted the resident on 12/7/23. Diagnoses included pressure ulcer to sacral region and type 2 diabetes mellitus.

Record review of Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 2/21/25 revealed the resident was rarely or never understood.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 255171 Department of Health & Human Services Printed: 09/03/2025 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 255171 B. Wing 03/27/2025

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

Winona Manor Health Care and Rehabilitation Center 627 Middleton Road Winona, MS 38967

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 47874

Level of Harm - Minimal harm or Resident #25 potential for actual harm

Record review of Resident #25's Order Listing Report revealed an order dated 12/27/24, Cleanse Residents Affected - Many unstageable pressure ulcer to tip of left great toe with wound cleanser or NS (normal saline), pat dry with 4 x 4 gauze, paint with betadine and cover with bordered gauze dressing q (every) Monday, Wednesday and Friday.

An observation of Resident #25's wound care with the Wound Care Nurse assisted by CNA #5 on 3/26/25 at 12:15 PM revealed that the care was provided without using a gown for EBP.

An interview with both the Wound Care Nurse and CNA #5 on 3/26/25 at 12:20 PM confirmed they did not dress out in a gown for EBP during Resident #25's wound care. They both revealed they had no knowledge of these precautions and indicated they had not been in-serviced or had any training on the subject.

An interview on 3/26/25 at 12:25 PM with CNA #2 and CNA #6 confirmed neither had been trained nor had knowledge of EBP.

An interview with the Regional Director of Clinical Services (RDCS) on 3/26/24 at 12:30 PM revealed the facility was currently working on getting EBP into place and confirmed staff had not been educated, and the precautions had not been practiced at the facility. She confirmed the purpose of using EBP was to protect

the residents from infection.

Record review of the Admission Record revealed the facility admitted Resident #25 on 9/15/23 with a medical diagnosis that included metabolic encephalopathy.

Resident #75

An observation of Resident #75 during medication administration on 3/26/25 at 8:00 AM revealed Licensed Practical Nurse (LPN) #4 attempted to flush the resident's PEG tube with water, but the tube was clogged. LPN #4 retrieved an opened package off the bedside table and indicated it was a peg tube declogger. The opened package was undated, and she inserted the declogger inside the resident's peg tube multiple times. Afterward, she rinsed the de-clogger and placed it back into the package. She administered the resident's medications via PEG tube without wearing a gown for EBP.

Review of the Bionix Enteral Feeding Tube Declogger manufacturer's instructions online revealed single use and discard after using.

An interview with LPN #4 on 3/26/25 at 8:47 AM confirmed the manufacturer's instructions revealed the tube declogger was for single use and revealed reusing the declogger placed Resident #75 at risk for infection. LPN #4 confirmed she did not wear a gown to administer the medications and indicated she had not been trained or had any in-services on using EBP.

On 3/26/25 at 3:21 PM, an interview with the RDCS with the Director of Nursing (DON) in attendance revealed the staff should not be using feeding tube de-cloggers and voiced there were other alternatives to handle a clogged tube.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 255171 Department of Health & Human Services Printed: 09/03/2025 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 255171 B. Wing 03/27/2025

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

Winona Manor Health Care and Rehabilitation Center 627 Middleton Road Winona, MS 38967

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 Record review of the Admission Record revealed the facility admitted Resident #75 on 3/07/24 with medical diagnoses that included sequelae of cerebral infarction and gastrostomy status. Level of Harm - Minimal harm or potential for actual harm 47157

Residents Affected - Many Resident # 32

During an observation of wound care for Resident #32 on 3/26/25 at 11:50 AM with the Wound Care Nurse and CNA #5, revealed the Wound Care Nurse or CNA #5 did not don a gown as part of the EBP.

A review of the March 2025 Treatment Record for Resident #32 revealed the following: Clean diabetic/PVD (peripheral vascular disease) right heel wound with wound cleanser, pat dry, apply collagen dressing with silver, cover with kerlix and secure with tape daily, signed off as completed on 3/26/25.

During an interview with the Wound Care Nurse and CNA #5 on 3/26/25 at 12:22 PM, it was confirmed that

they did not wear any special PPE for EBP during Resident #32's wound care and that they had not been in-serviced or trained on EBP.

A review of Resident #32's Admission Record revealed that he was admitted on [DATE REDACTED], with a diagnosis of Type II diabetes.

During an interview with the Infection Control (IC) Nurse on 3/26/25 at 2:51 PM, she revealed that she was aware of what EBP was because she learned about it in her Infection Control training. She stated that EBP is used as an extra layer of protection between residents and staff to reduce the spread of infection for residents with open wounds and indwelling devices. She confirmed that the facility was not using EBP for any residents. She also revealed she was unaware of why the facility did not educate staff or implement EBP practice.

During an interview with the Administrator on 3/26/25 at 3:00 PM, he revealed that he was not aware staff were not using EBP. He stated that the facility had been using EBP at one point but experienced a breakdown in its practice due to significant staff turnover in the past six months.

During a follow-up interview with the Administrator on 3/27/25 at 10:48 AM, he confirmed that concerns from failing to educate and implement EBP is that high-risk residents would not receive the necessary precautions.

48845

Resident # 65

During an observation on 3/25/25 at 11:05 AM of Resident #65 revealed he was lying in bed with a biliary drain connected to a drainage bag. The biliary drainage collection bag with a brown, foamy substance was lying on the floor visible from the doorway.

During an observation and interview on 3/26/25 at 10:07 AM with LPN) #2, it was confirmed the biliary drainage collection bag should not be on the floor. She further confirmed that the bag being on the floor was

an infection control issue. She stated, the floor is the nastiest place!

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 255171 Department of Health & Human Services Printed: 09/03/2025 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 255171 B. Wing 03/27/2025

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

Winona Manor Health Care and Rehabilitation Center 627 Middleton Road Winona, MS 38967

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 3/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) it was confirmed

the that the biliary drainage collection bag should not have been on the floor as that is an infection control Level of Harm - Minimal harm or concern that could lead to an infection to the resident. potential for actual harm

Record review of Order Summary Report confirmed Resident #65 had orders related to a biliary drain with Residents Affected - Many start date 2/28/25.

Record review of Admission Record revealed the facility admitted Resident #65 on 3/9/25 with medical diagnoses that included Malignant Neoplasm of Pancreas, and Obstruction of Bile Duct.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 255171